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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802467
Report Date: 03/18/2022
Date Signed: 03/18/2022 07:54:38 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/24/2020 and conducted by Evaluator Kasandra Lopez
COMPLAINT CONTROL NUMBER: 29-AS-20200624150217
FACILITY NAME:PALMS AT BONAVENTURE ASSISTED LIVING, THEFACILITY NUMBER:
565802467
ADMINISTRATOR:MCCAULEY, BRANDYFACILITY TYPE:
740
ADDRESS:111 N WELLS ROADTELEPHONE:
(805) 647-0616
CITY:VENTURASTATE: CAZIP CODE:
93004
CAPACITY:121CENSUS: 92DATE:
03/18/2022
UNANNOUNCEDTIME BEGAN:
12:38 PM
MET WITH:Brandy McCauleyTIME COMPLETED:
07:05 PM
ALLEGATION(S):
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Staff did not properly transfer resident resulting in a fall
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced subsequent complaint inspection at the facility today. The LPA met with Administrator Brandy McCauley at 12:41 PM and explained the reason for today's visit.
During the previous virtual inspection on 07/01/2020, at approximately 11:40 AM, LPA conducted a physical plant tour of the facility utilizing a video call with Ms. McCauley. The LPA observed five resident rooms in Assisted Living and five resident rooms in the Memory Care unit. The LPA also met with five residents in the memory care unit and conducted brief interviews.
During today's inspection, the LPA conducted a physical plant tour with the Administrator beginning at 1:46 PM. Between 12:46 PM and 1:45 PM, the LPA observed four resident rooms in Assisted Living and four resident rooms in Memory Care. The LPA also conducted interviews with Resident #1 (R1) at 1:00 PM, and five staff between 1:51 PM and 4:00 PM. The LPA reviewed facility records beginning at 4:07 PM. At 5:07 PM the LPA conducted an interview with the Administrator. Report continued on LIC 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 29-AS-20200624150217
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: PALMS AT BONAVENTURE ASSISTED LIVING, THE
FACILITY NUMBER: 565802467
VISIT DATE: 03/18/2022
NARRATIVE
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The allegation of 'Staff did not properly transfer resident resulting in a fall' alleged Resident #2 (R2) who is a two person assist with use of a mechanical lift, fell from their wheelchair due to Staff #1 (S1) assisting R2 alone and not properly setting R2 on the wheelchair using the lift.

Record review revealed, in the March 31, 2020 service plan, states that two staff must be present during all mechanical lifts for all transfers for R2. Interviews revealed R2 sustained a fall when S1 transferred R2 using the lift without assistance from another staff as indicated in the service plan. Record review revealed R2 had a witnessed fall on 06/22/2020 when staff was trying to readjust the resident in their wheelchair and the resident slipped out. No injuries were noted. It is noted to use the hoyer lift and two person assist when getting the resident back into the wheelchair. Based on the information obtained, there is sufficient evidence to support the allegation occurred, therefore the above allegation is deemed Substantiated at this time.

Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D).

Exit interview conducted, and report reviewed with the Administrator. A copy of this report and appeal rights will be issued.



SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20200624150217
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PALMS AT BONAVENTURE ASSISTED LIVING, THE
FACILITY NUMBER: 565802467
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
03/31/2022
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement is not met as evidenced by:
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The Administrator shall ensure all staff, have training regarding the use of a mechanical lift/tranfer training and reviewing serivces plans and submit proof to CCL by 3/31/2022.
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Based on interviews and record review , the licensee failed to comply with the section cited above as R2 sustained a fall as a result of S1 not following R2's service plan when lifting R2 which poses an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/24/2020 and conducted by Evaluator Kasandra Lopez
COMPLAINT CONTROL NUMBER: 29-AS-20200624150217

FACILITY NAME:PALMS AT BONAVENTURE ASSISTED LIVING, THEFACILITY NUMBER:
565802467
ADMINISTRATOR:MCCAULEY, BRANDYFACILITY TYPE:
740
ADDRESS:111 N WELLS ROADTELEPHONE:
(805) 647-0616
CITY:VENTURASTATE: CAZIP CODE:
93004
CAPACITY:121CENSUS: 92DATE:
03/18/2022
UNANNOUNCEDTIME BEGAN:
12:38 PM
MET WITH:Brandy McCauleyTIME COMPLETED:
07:05 PM
ALLEGATION(S):
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Residents are not being provided clean linen
Resident was left on the floor for an extended period of time
Staff hit resident
Residents are not properly bathed
Resident sustained an unexplained injury while in care
Staff handles resident in a rough manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced subsequent complaint inspection at the facility today. The LPA met with Administrator Brandy McCauley at 12:41 PM and explained the reason for today's visit.
During the previous virtual inspection on 07/01/2020, at approximately 11:40 AM, LPA conducted a physical plant tour of the facility utilizing a video call with Ms. McCauley. The LPA observed five resident rooms in Assisted Living and five resident rooms in the Memory Care unit. The LPA also met with five residents in the memory care unit and conducted brief interviews.
During today's inspection, the LPA conducted a physical plant tour with the Administrator beginning at 1:46 PM. Between 1:46 PM and 1:45 PM, the LPA observed four resident rooms in Assisted Living and four resident rooms in Memory Care. The LPA also conducted interviews Resident #1 (R1) at 1:00 PM, and five staff between 1:51 PM and 4:00 PM. The LPA reviewed facility records beginning at 4:07 PM. At 5:07 PM, the LPA conducted an interview with the Administrator. Report continued on LIC 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20200624150217
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: PALMS AT BONAVENTURE ASSISTED LIVING, THE
FACILITY NUMBER: 565802467
VISIT DATE: 03/18/2022
NARRATIVE
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The allegation of 'Residents are not being provided clean linen' alleges staff does not change resident's soiled linens. During today's inspection, and during the previous inspection, the LPA observed 18 resident rooms and observed clean linens and bedding in each room. Interviews with R1 and staff today, indicated no history of residents having soiled linens. Based on the information obtained, there is insufficient evidence to support the allegation occurred, therefore the allegation of 'Residents are not being provided clean linen' is deemed unsubstantiated at this time.

The allegation of 'Resident was left on the floor for an extended period of time' alleges Resident #3 (R3) was left on the floor for hours after a fall. Interviews and record review revealed although R3 had documented falls near the end of their life, there is no evidence to support the allegation occurred. Based on the information obtained, there is insufficient evidence to support the allegation occurred, therefore the allegation of 'Resident was left on the floor for an extended period of time' is deemed unsubstantiated at this time.

The allegations of 'Staff hit resident' and 'Residents are not properly bathed' alleged two unknown staff used dish soap and paper towels when showering R4 and one of these two staff hit R4 on the back when showering R4. Interviews revealed no knowledge of staff using dish soap or paper towels when showering R4 and no knowledge of any staff hitting R4. R4 has since passed away. When conducting the physical plant tour, the LPA observed body wash and other hygiene items in each resident bathroom. Based on the information obtained, there is insufficient evidence to support the allegation occurred, therefore the allegations of 'Staff hit resident' and 'Residents are not properly bathed' is deemed unsubstantiated at this time.

The allegation of 'Staff handles resident in a rough manner' alleged Staff #2 (S2) pulled the arm of Resident #5 (R5) while R5 was being changed. S2 no longer works for the facility due to unrelated reasons. Interviews revealed no history of S2 being rough with any residents. The last name of R5 was not provided with the complaint so it is unclear who R5 may be. Based on the information obtained, there is insufficient evidence to support the allegation occurred, therefore the allegations of 'Staff handles resident in a rough manner' is deemed unsubstantiated at this time.

Report continued on LIC 9099-C
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20200624150217
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: PALMS AT BONAVENTURE ASSISTED LIVING, THE
FACILITY NUMBER: 565802467
VISIT DATE: 03/18/2022
NARRATIVE
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The allegation of 'Resident sustained an unexplained injury while in care' alleged Resident #6 had an unexplained injury of two swollen fingers. The complainant only provided a first name for R6 who resided in the memory care. During the initial inspection on 07/01/2020, the LPA virtually met with two residents with the same name as R6. The LPA was unable to interview them due to their impairments. The Administrator was not aware of any injuries to either resident at the time. Interviews today revealed no history of injuries of the hand to any residents with R6's name. Based on the information obtained, there is insufficient evidence to support the allegation occurred, therefore the allegations of 'Resident sustained an unexplained injury while in care' is deemed unsubstantiated at this time.

Exit interview and report reviewed with Administrator. A copy of the report and appeal rights will be issued.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6