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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802467
Report Date: 10/08/2021
Date Signed: 10/12/2021 09:02:37 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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, THEFACILITY NUMBER:
565802467
ADMINISTRATOR:MCCAULEY, BRANDYFACILITY TYPE:
740
ADDRESS:111 N WELLS ROADTELEPHONE:
(805) 647-0616
CITY:VENTURASTATE: CAZIP CODE:
93004
CAPACITY:121CENSUS: 92DATE:
10/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Brandy McCauleyTIME COMPLETED:
02:30 PM
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Licensing Program Analysts (LPA) Angel Ascencio arrived at the facility unannounced to conduct a required annual visit at 12:51 p.m. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Administrator Brandy McCauley and discussed the reason for the visit. Entrance interview conducted.

The LPA, along with the Admin toured the physical plant areas inside and outside at 1:20 p.m. to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations.

BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 104 total bedrooms; 72 (seventy-two) are in assisted living and 28 (twenty-eight) are in memory care; with 16 (sixteen) shared and 12 (twelve) private apartments there.

RESTROOMS: Public and resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. The LPA observed sufficient amounts of soap and paper products in each restroom, as well as hand washing posters.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, common seating area and dining room furniture was observed to be in good condition. Chairs were observed to be at least 6 (six) feet apart for social distancing. The LPA observed the required postings in the common hallway. Fire extinguishers were observed to be serviced within the last year.

Continued on LIC 809 - C

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/08/2021
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The courtyard has a covered outdoor area equipped with furniture, that was in good repair, for resident use. There were no bodies of water noted. LPA observed different locked storage rooms which contained emergency food supply. Medication room was observed to be locked containing resident files and at least 30 (thirty) days worth of medication supply for residents.

KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices around 1:00 p.m. There is only 1 entry into the facility. Upon entry, the facility has a central entry point for symptom screening. The LPA noted that the facility is allowing visitors for both indoor and outdoor visitation. Per PIN, facility is obtaining a copy of the vaccination card or require a 72 (seventy-two) hour COVID-19 test to be taken for visitation. The LPA observed at least a 30 (thirty) day supply of Personal Protective Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. The facility has had a confirmed case of COVID-19. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility does not have a confirmed case of COVID-19 at this time. The facility’s policies and procedures as it pertains to infection control are adequate.

The following recommendations were made:



- Post PINs and educate staff, residents, and families on changing policies and procedures from the Department

No citations were issued during today’s visit. Exit interview conducted. A copy of the report was provided via email to the administrator.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021
LIC809 (FAS) - (06/04)
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