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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802467
Report Date: 05/13/2024
Date Signed: 05/24/2024 01:33:34 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
04/10/2023 and conducted by Evaluator Zabel Chochian
COMPLAINT CONTROL NUMBER: 29-AS-20230410091906
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: 89DATE:
05/13/2024
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Brandy McCauleyTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff caused injury to resident
Resident sustained injuries while in care
Facility did not properly transfer resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to deliver findings for the above allegations. LPA met with Executive Director Brandy McCauley and explained the reason for the visit.

On 04/10/2023, the Department received a complaint of Neglect/Lack of Care and Supervision alleging staff caused injury to Resident #1 (R1). It was alleged R1 sustained injuries while in care and the facility did not properly transfer R1. The complaint was referred to the Community Care Licensing Investigations Branch (IB) and assigned to Investigator Juan Lozano.

On 04/12/2023, from 11:45 a.m. to 3:45 p.m., LPA Chochian conducted an unannounced complaint visit. The LPA reviewed facility incident reports for 2022-2023 and reviewed ten (10) resident records from 12:00 p.m. to 3:00 p.m. During the visit, the LPA was given a tour of the facility by staff Harmony Langarica.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2024
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 7
Control Number 29-AS-20230410091906
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: 05/13/2024
NARRATIVE
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On 06/07/2023, at 11:45 a.m., Investigator Lozano conducted interviews with the Reporting Party (RP) and at 12:30 p.m., attempted to interview R1 who was unable to answer questions due to cognitive decline; on 06/23/2023, at 10:15 a.m., with the Executive Director/Administrator; and on 07/10/2023, at 3:45 p.m., with Staff #1 (S1). In addition, Investigator Lozano reviewed facility file documents related to R1, photos, and facility incident report dated 03/30/2023.

The investigation revealed that R1 was non-ambulatory and required assistance with transfers. Per the facility incident report, on 03/30/2023 at 7:30 a.m., S1 was assisting R1 with a transfer via the assisstive device “Sara Lift”. While on the Sara Lift, R1 went limp and was unable to provide support during the transfer. S1 requested additional help assisting R1 off the Sara Lift and onto the wheelchair. The incident report documented that a strap was “placed slightly loose on R1”. The report documented that R1 had carpet burn to R1’s knees; R1 displayed discomfort, was given Tylenol for pain; and ointment and band aid applied to both knees.

During the interview process, S1 stated that they were trained on how to use the Sara Lift as a single user and as a two-person operation. S1 indicated that they were doing a solo transfer of R1 from bed to wheelchair and during the transfer R1 slid down the Sara Lift due to a loose-fitted shirt. Immediately after observing R1 slide down the Sara Lift, S1 lowered the Sara Lift which caused R1 to end up on the ground on both knees. S1 stated that while they were lowering R1 and the Sara Lift, S1 simultaneously used their handheld radio to call for help. Less than a minute later, the med tech entered R1’s room and assisted S1 with lifting R1 from the ground onto the wheelchair. S1 stated they believed the incident could have been prevented. S1 added that transferring clients with two people could have prevented the incident because as soon as R1 slid while on the Sara Lift, they would have not lowered R1 to R1’s knees, but rather provided immediate support to R1 while on the Sara lift to prevent R1 from sliding.

A physician communication note dated 03/30/2023, from the facility LVN to Dr. Zylstra requested the use of a Hoyer Lift and hospice placement for R1. The communication note stated, “the Sara Lift is not working for R1” and “this is not safe for resident or caregiver”; “R1’s body is stiff and R1 is resistant to care with a decline noted”. On 04/03/2023, R1 was placed on hospice services with a supply order which included a Hoyer Lift.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 29-AS-20230410091906
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: 05/13/2024
NARRATIVE
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Based on the evidence and statements made during the course of the investigation, the Department determined there is sufficient evidence to conclude that R1 was not properly transferred which caused injuries resulting from the transfer. The incident report indicated that a strap on the Sara Lift was placed slightly loose on R1. The loose strap possibly was a contributing factor that caused R1 to slide down the Sara Lift, which caused R1 to be lowered on the Sara Lift to their knees leaving apparent injuries to both of R1’s knees. Therefore, the Neglect/Lack of Care and Supervision allegations “Staff caused injury to resident”, “Resident sustained injuries while in care”, and “Facility did not properly transfer resident” are deemed Substantiated at this time.

A $500 immediate civil penalty is assessed today.

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

Exit interview conducted, appeal rights discussed, and a copy of this report issued.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 29-AS-20230410091906
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: 05/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/14/2024
Section Cited
HSC
1569.312(a)
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Basic services requirements. Basic services shall at a minimum include: (a) Care and supervision as defined in Section 1569.2.
This requirement is not met as evidenced by:

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Licensee will submit a plan how they will ensure staff to properly transfer residents. Submit to CCL by due date.

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Based on interviews and records review, the licensee did not comply with the section cited above. Facility staff failed to properly transfer R1 which caused R1 to be lowered on the Sara Lift to their knees leaving apparent injuries to both of R1’s knees.
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This posed 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: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 7
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
04/10/2023 and conducted by Evaluator Zabel Chochian
COMPLAINT CONTROL NUMBER: 29-AS-20230410091906

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: DATE:
05/13/2024
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Brandy McCauleyTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility did not provide records to resident's responsible party.
Facility did not report resident's illness to responsible party.
Facility staff did not properly assist resident with medications.
Hazardous items are accessible to residents in care.
Facility retaliated against resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to the facility. The purpose of the visit is to deliver investigation finding. Upon arrival LPA met with Executive Director Brandy McCauley and explained the reason for the visit. Entrance interview conducted.

On 04/10/2023, Community Care Licensing Division received the above complaint allegations. Investigation into the allegations consist of facility physical plant tour on 04/12/2023, records review and interview with staff on 04/12/2023, 06/23/2023, 07/10/2023, 04/04/2024 and 04/09/2024. In addition, random residents and potential witnesses were interviewed on 06/07/2023 and 05/05/2024. On 4/12/2023, 03/13/2024, 04/04/2024 and 05/04/2024, LPA attempted to contact Reporting Party (RP) but was not successful.

Following is a summary of the allegations and investigation finding: Allegation) Facility did not provide records to resident's responsible party. It was alleged that the facility did not provide Resident #1’s responsible party with copies of incident reports when requested. (Continue to LIC9099c)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 29-AS-20230410091906
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: 05/13/2024
NARRATIVE
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Interview with staff and records reviewed revealed that incidents pertaining to R1 were reported to the responsible party and physician accordingly. Several attempts were made to contact resident #1’s (R1) responsible party and the reporting party to determine the validity of this allegation however no return call was received. Random resident responsible parties interviewed reported no issues with receiving any records when requested and confirmed receiving notification of incidents which involved their loved ones. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Facility did not provide records to resident’s responsible party” is deemed unsubstantiated at this time.

Allegation) Facility did not report resident's illness to responsible party. It was alleged that facility administration did not notify R1, and visitors of the Norovirus outbreak in 2/2023. Records reviewed confirmed the facility had one (1) staff test positive for COVID on 2/13/2023 which was reported to Community Care Licensing (CCL) on 2/15/2023 when facility was made aware of the positive results. In addition, on 03/02/2023, facility had a Norovirus outbreak which was also reported to the CCL and Ventura County Public Health (VCPH). Residents were placed on contact precautions and communal dining was closed as well as group activities based on VCPH guidelines. Random residents and responsible parties interviewed confirmed receiving notification of the positive COVID case in 2/2023 and the Norovirus outbreak in 03/2023 by facility. Several attempts were made to reach reporting party regarding this allegation however no return call was received. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Facility did not report resident’s illness to responsible party” is deemed unsubstantiated at this time.

Allegation) Facility staff did not properly assist resident with medications.
It was reported that medications were found in R1’s room multiple times; staff refuse to crush medication “Xarelto”; R1’s medications are “dispensed late or not dispensed at all”. Records reviewed revealed that it was discovered that R1 was cheeking medications and spitting it out after staff left the room. Staff expressed this is why medications were found in R1’s room. Staff reported that R1 was monitored closely for this behavior however R1 would manage to still hide medication and spit it out when staff left. It was documented by staff that R1 did not like the taste of the medication therefore, would spit it out. Records reviewed confirmed that contact was made with R1’s physician once it was discovered that R1 was cheeking the medication and spitting it out regularly. (Continue to page LIC9099c)
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 29-AS-20230410091906
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: 05/13/2024
NARRATIVE
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 Documentation in R1’s file confirmed that R1’s physician was contacted, and an order was obtained to have medications crushed and mixed with applesauce for R1 to easily take without any discomfort. Staff interviewed denied allegation and expressed that medication are given to residents according to the physician orders as stated on the prescriptions. Several attempts were made to contact reporting party regarding this allegation however no return call was received. Interview was attempted with R1 however R1 was unable to answer basic questions asked due to diagnosis. Twelve (12) out of twelve (12) resident records reviewed on 04/12/2023 did not reveal any medication discrepancies. Ten (10) random potential witnesses interviewed did not report any issues with residents receiving their medications. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Facility staff did not properly assist resident with medications” is deemed unsubstantiated at this time.

Allegation) Hazardous items are accessible to residents in care. It was alleged that open, unsecured bio hazard waste containers are placed in carpeted pedestrian corridors. During the initial visit on 4/12/2023, a physical plant tour was conducted, and LPA did not observe any bio hazard containers in any corridors. Ten (10) random potential witnesses interviewed did not report seeing any unsecured bio hazard waste containers in the facility or any hazardous items accessible to residents in care. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Hazardous items are accessible to residents in care” is deemed unsubstantiated at this time.

Allegation) Facility retaliated against resident. It was alleged that facility administration initiated retroactive price increases without notice and subsequent eviction threats were made to R1 because of complaints filed. Administrator denied allegation Information provided was that the increase in rent was due to change in level of care and this was discussed with the resident’s responsible person. Several attempts were made to contact R1’s responsible party and reporting party to determine the validity of this allegation however no return call was received. Interview was attempted with R1, however R1 was unable to answer basic questions asked due diagnosis. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Facility retaliated against resident” is deemed unsubstantiated at this time.

Exit interview conducted. A copy of the report provided.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7