565802467-12-14-2023-29-AS-KLOZ-CYNP7Z-20231219100442

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802467
Report Date: 12/14/2023
Date Signed: 12/14/2023 11:30:03 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/14/2021 and conducted by Evaluator Esther Cortez

COMPLAINT CONTROL NUMBER: 29-AS-20210514112111

FACILITY NAME:	PALMS AT BONAVENTURE ASSISTED LIVING, THE		FACILITY NUMBER:	565802467
ADMINISTRATOR:	MCCAULEY, BRANDY		FACILITY TYPE:	740
ADDRESS:	111 N WELLS ROAD		TELEPHONE:	(805) 647-0616
CITY:	VENTURA	STATE: CA	ZIP CODE:	93004
CAPACITY:	121	CENSUS:	DATE:	12/14/2023
		UNANNOUNCED	TIME BEGAN:	08:21 AM
MET WITH:	Brandy McCauley		TIME COMPLETED:	11:35 AM

ALLEGATION(S):

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Resident sustained a pressure injury while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Esther Cortez conducted a subsequent complaint visit to deliver findings for the above allegation. The LPA met with Administrator Brandy McCauley and explained the reason for the visit.

On 05/17/2021, LPA Rosales conducted the initial 10-day complaint visit from 11:25 AM – 6:00 PM, the LPA reviewed resident records, obtained copies of pertinent documents, and interviewed residents. LPA Smith conducted a subsequent complaint visit on 06/13/2023 from 9:45 AM – 2:30 PM, interviewed nine (9) staff, conducted a medication audit, and interviewed four (4) residents. On 10/03/2023, LPA Cortez toured the facility with administrator Brandy McCauley at 10:00 am, reviewed all staff and resident interviews conducted by LPA Rosales and Smith, and interviewed two (2) staff and two (2) residents between 10:20 a.m. and 11:30 a.m.
Report will continue on LIC9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20210514112111

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PALMS AT BONAVENTURE ASSISTED LIVING, THE	FACILITY NUMBER: 565802467
	VISIT DATE: 12/14/2023

NARRATIVE

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On 12/05/2023 and 12/06/2023 LPA Cortez conducted phone interviews with Individual #1 (I1) who cared for R1 in 2021. The allegation of Resident sustained a pressure injury while in care, alleges concern of the reporting party that due to not receiving incontinence care regularly, one resident (Resident #1 (R1)) had skin break down resulting in a “black bottom”.

Review of R1’s service plan dated 08/13/20, indicated R1 needed assistance with urinary incontinence around the clock, used adult disposable diapers during the night and needed to be changed at least one time during the night. It further indicated that due to R1 having a slow-healing wound on their buttocks, they needed to be transferred back to bed between meals and positioned on their side to avoid pressure to the wound area. R1’s service plan also indicated they used an electric-powered air mattress to relieve pressure and the bed had bed rails used for repositioning. The service plan indicated R1 was at risk for skin breakdown and staff was to reposition every two hours.

During the investigation, the LPAs conducted interviews with various residents and staff. Resident Interviews revealed that staff regularly check residents and change their diapers, and even though there have been times when a resident has been left soiled, it was rare. During the interview with R1, conducted by LPA Rosales, R1 stated the nurse comes in almost every day to check on their wound and staff would come in two to three times a day to check on R1, however, they were not being turned every 2 hours or every day. Staff interviews revealed that residents are changed approximately every two hours or as needed.

During the 05/17/21 visit, LPA Rosales obtained hospice visit records from the facility records. Additionally, on 10/19/23 LPA Cortez obtained subpoenaed records from Livingston Memorial Visiting Nurse Association & Hospice. Interview revealed R1 started receiving hospice care services on 10/30/2020. Records indicate R1 was regularly seen by hospice nurses, and home health. Records revealed that on 01/18/21, R1 was observed by hospice to have a stage 2 pressure injury on the sacral region. Hospice instructed the staff to apply barrier cream but to not put dressing on the wound and reposition R1 every 2-4 hours. Hospice records revealed that on 02/16/21 a telehealth call was made to R1’s family member from hospice, to discuss options of higher level of care should the facility be unable to manage R1’s skin care needs. However, R1 was pleased with the care being provided by the facility and hospice records revealed that R1’s family member stated that R1 had lived in several facilities previously and they were happy with the care R1 was receiving.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20210514112111

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PALMS AT BONAVENTURE ASSISTED LIVING, THE	FACILITY NUMBER: 565802467
	VISIT DATE: 12/14/2023

NARRATIVE

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On 02/23/21, R1 was observed by Registered Nurse Certified Hospice and Palliative Nurse (RN CHPN) to have their buttocks wound healed, however R1’s sacral area was noted to have numerous places of scaring from healed stage 2 pressure wounds. Hospice visit documentation also revealed that on 02/23/21, R1 was observed by the RN CHPN to have an unstageable wound to posterior right leg 7cm x 3 cm. Records further revealed that the right leg wound was 100 percent eschar. The RN CHPN gave facility wound orders and treatments for R1 as well as training for the caregiving staff on wound care.

A review of the subpoena hospice records noted that on 03/26/2021, hospice staff completed the “Braden Scale for Predicting Pressure Sore Risk in Home Care”, and R1 had a total score of 12, which was indicated as “high risk” for pressure injuries. It was also documented that R1’s wound to right posterior lower leg was reported to have started out as a blister from a possible autoimmune condition. By 03/26/21, R1 was receiving wound care from hospice nurses three (3) times a week and four times a week by facility nurse. R1 was also receiving care from home health two to three times a week.

Interviews with a Livingston Memorial Hospice Nurse who cared for R1 revealed that R1 had poor nourishment by choice as they were refusing to eat, and that staff was reporting R1 was also refusing to take their medications. When asked if facility staff was culpable for R1’s wounds, they went on to state, “I don't think anybody is culpable for that. It's just you know, it is what it is. Unless you have a patient that is eating and taking in calories, nourishment, they're not going to heal.”

Based on the information obtained during the investigation, there is insufficient evidence to support the claim that a Resident sustained a pressure injury while in care, due to not receiving incontinence care regularly. Therefore, the allegation is deemed Unsubstantiated at this time.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued to the administrator.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

LIC9099 (FAS) - (06/04)

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