565802467-9-19-2024-29-AS-ECOZ-D9A3DY-20240919181018

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565802467
Report Date: 09/19/2024
Date Signed: 09/19/2024 06:10:30 PM

Document Has Been Signed on 09/19/2024 06:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
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: 86	DATE:	09/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Brandy Mccauley		TIME COMPLETED:	06:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At 01:40 p.m. Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit. The LPA met with Executive Director (ED) Brandy McCauley and informed them of the reason for the visit. At 2:00 p.m. the LPA conducted a tour of the physical plant with the ED to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The following was noted: Facility is a double-story residence that consists of a memory care unit, and an assisted living unit. The LPA observed fire extinguishers throughout the facility, which were fully charged and last serviced 04/09/2024. The smoke alarms and carbon monoxide detectors were tested and functioned properly. The LPA observed all required postings in the hallways near the entrance area. The facility serves residents with dementia, at 3:49 p.m. the auditory alarms on the exit doors were tested and the LPA observed the gates to the memory care courtyard locked. Upon observation, the ED stated that they had to lock the gate because they delay aggress was not sending notifications to staff and they were in the process of getting it fix. Kitchen: During the facility tour, the kitchen appeared clean and the appliances and fixtures functional. The LPA observed a sufficient amount of perishable and non-perishable food at the facility. Food is prepared based on the menu. Snacks and beverages are available for residents in the dining area. At 2:10 p.m. the LPA observed 2 packs of Whole Wheat bread with the expiration date of 09/13/2024. At 3:07 p.m. the following emergency food items were observed expired or without an expiration or best by label: 7- 50oz cans of of Tomato Campbell's soup with the expiration date of 28 Oct 23, 5- large cans of Cream Style corn with no expiration date, 6 large cans of Pork and Beans with no expiration date, 6 large cans of cut sweet potatoes with no expiration date, 4-8oz cans of Fruit cocktails with no expriation date, and 6 large cans of garbanzo beans with no expiration dates. Report will continue on LIC809-C.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

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 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/19/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Bedrooms: During today’s visit, the LPA observed ten (10) randomly selected resident units. The resident bedrooms were properly furnished. The bedrooms had appropriate and adequate beddings. At 2:15 p.m. the LPA observed Aspercreme Lidocaine pain relief cream in room 224, per the residents physician's report (LIC602) the resident cannot store or administered medications. At 2:20 p.m. the LPA observed the following in room 208: a light in the bathroom that was not operable, a light that was not operable outside the restroom, a bottle of B-6/Folic Acid pills, and a bottle of Melatonin. The resident in room 208 cannot store or administered medications per their LIC602. At 2:33 p.m. the LPA observed the light outside the bathroom not operable in room 223. At 2:39 p.m. the LPA observed IcyHot pain Relief cream in room 219, and a light in the kitchen that was not operable. The resident in room 219 is not able to store or administer medications per their LIC602. At 3:33 p.m. the LPA observed the following in room 138 in memory care: a bottle of milk of Magnesium, a bottle of Rubbing Alcohol, ants on the residents bed, and ants in the bathroom sink. At 3:40 a.m. the LPA observed ants and three bottles of Fabreeze in room 141 in memory care. At 3:48 p.m. the LPA observed ants and a bug in the bathroom of room 139 in memory care.

Bathrooms: The LPA observed ten (10) bathrooms, properly supplied and had functional fixtures. The LPA observed grab bars and non-skid mats in all bathrooms. Water temperature measured in the restrooms ranged between 110.1 degrees Fahrenheit and 118.4 degrees Fahrenheit.

Common Areas: These included the library, workout room, and dining areas in assisted living and memory care units. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. Fireplaces were properly screened.

Surrounding Grounds (Outdoors): The LPA observed appropriate outdoor furniture, with a covered shaded area for residents in both, the memory care unit courtyard and the assisted living courtyard. Parking is available for residents and visitors.
Interviews: The LPA conducted four (4) resident interviews. No immediate concerns were voiced Due to time constraints an LPA will return at a later date to complete the annual.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Civil penalties assessed in the amount of $500.00 were issued. Exit interview conducted. Todays reports, appeal rights and civil penalties were reviewed with Executive Director Brandy and provided..

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

LIC809 (FAS) - (06/04)

Page: 2 of 5

Document Has Been Signed on 09/19/2024 06:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview the licensee did not comply with the section cited above as fire clearance indicates delayed egress is approved, however, an outdoor gate with delayed egress was non-functional and was subesquently locked with a comination cable lock which poses an immediate safety risk to residents in care.
	POC Due Date: 09/20/2024
	Plan of Correction
1 2 3 4	ED agreed to take off the combination cable lock of the gate in the memory care unit and submit a plan on how they will ensure the safety of residents and facility compliance with the fire clearance to CCL by 09/20/2024.

Type A

Section Cited

CCR

87465(h)(2)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above in three out of ten resident rooms that were observed with medications, and residents in those rooms cannot store or administer medications per their LIC602 which poses an immediate health and safety risk to persons in care.
	POC Due Date: 09/20/2024
	Plan of Correction
1 2 3 4	ED agrees they will remove all medications from the three rooms and submit a plan on how they will ensure they are in compliance with regulation 87465 to CCL by 09/20/2024.

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: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 09/19/2024 06:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(2)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on onservation the licensee did not comply with the section cited above in one memory care resident's room that contained milk of magnesium and rubbing alcohol which poses an immediate health and safety risk to persons in care.
	POC Due Date: 09/18/2024
	Plan of Correction
1 2 3 4	POC has been met, ED removed items from the room.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 09/19/2024 06:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in three memory care rooms that were observed with ants, and three assisted living resident rooms that were observed with non-operating lights which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/23/2024
	Plan of Correction
1 2 3 4	ED agress to have all three rooms in memory care cleaned and inspected for ants and/or ther insects, and have all non operable lights fixed and submit to CCL by 09/23/24. Proof can be photos, or service invoices.

Type B

Section Cited

CCR

87555(b)(8)

General Food Service Requirements

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in as the LPA observed emergency food expired or without an expiration date which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/23/2024
	Plan of Correction
1 2 3 4	ED agrees to have staff audit the emergency food supply and discard of all expired food and replace it and submit proof to CCL by 09/23/2024.

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: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

LIC809 (FAS) - (06/04)

Page: 5 of 5