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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802467
Report Date: 04/29/2024
Date Signed: 04/29/2024 12:33:58 PM

Unsubstantiated


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
11/21/2023 and conducted by Evaluator Kelly Dulek
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20231121084529
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: 88DATE:
04/29/2024
UNANNOUNCEDTIME BEGAN:
11:16 AM
MET WITH:Brandy McCauleyTIME COMPLETED:
11:29 AM
ALLEGATION(S):
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Due to neglect, resident received the wrong medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced subsequent complaint visit for the allegation listed above. Due to Public Health concerns at the facility, today’s visit was conducted via telephone with the facility Executive Director (ED) Brandy McCauley. Entrance interview conducted.

During an initial complaint visit conducted on 11/22/2023, at 09:36AM, LPA along with ED, toured the facility. LPA reviewed facility incident records for October - November 2023 and reviewed and obtained copies of pertinent documents. A referral was made to Community Care Licensing Division's (CCLD) Investigation Branch (IB). IB Investigator Dennis Seng then continued the investigation into the above allegation. Investigator Seng conducted both telephonic and in person interviews with relevant parties on the following dates: 12/13/2023, 12/14/2023, 02/16/2024. Throughout the course of the investigation, Investigator Seng reviewed medical records for Resident #1 (R1), who was named in the complaint. The following was then determined:
Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024
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 2
Control Number 29-AS-20231121084529
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: 04/29/2024
NARRATIVE
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It was alleged that Resident #1 (R1) was given Fentanyl, which is not prescribed for R1, resulting in an overdose. On 11/18/2023, R1 was observed by their family member to be more lethargic and unresponsive than normal, which was reported to the facility staff. Facility staff then called 9-1-1 and medical responders noted that R1 had a patch on, resembling a Fentanyl patch. Upon admittance to the hospital, R1 was given a urology test, which appeared to have a positive result for Fentanyl. R1 was later re-tested with a serology test, which had a negative result for Fentanyl. Medical personnel interviewed indicated that serology tests are more accurate than the initial urology test and that the negative result on the serology test confirmed that R1 was “never exposed to any Fentanyl.” Medical personnel also added that a false positive result from a urology test is common. Interviews with facility staff and record review confirmed that R1 was prescribed a daily lidocaine patch. At the time of R1’s hospitalization, R1 had been prescribed an additional medication, Gabapentin, which has a side effect of drowsiness. Interview with R1’s family member revealed that “there was no fentanyl in [R1’s] system, it was a giant misunderstanding.” R1’s family member indicated that the Gabapentin had been recently prescribed to R1 and as a result of that medication, R1 was observed to be lethargic. While R1 was unable to complete an interview, other residents interviewed indicated the care they receive at the facility is good and residents are unaware of any incidents of neglect or lack of supervision that led to overdoses in the facility. Based on interview and record review, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation “due to neglect, resident received the wrong medication” is deemed UNSUBSTANTIATED at this time.

No citations issued. Exit interview conducted. A copy of today’s report was provided via email for signature.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2