565802467-10-18-2023-29-AS-ECOZ-CWR3VR-20231018183534

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565802467
Report Date: 10/18/2023
Date Signed: 10/18/2023 06:36:57 PM

Document Has Been Signed on 10/18/2023 06:36 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: 93	DATE:	10/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Brandy McCauley		TIME COMPLETED:	06:45 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 08:30 a.m. Licensing Program Analysts (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit. The LPA was greeted by staff and informed them of the reason for the visit. Administrator Brandy McCauley and LPA Jenny Olson arrived shortly after approximately at 9:10 a.m. At 10:12 a.m. the LPAs conducted a tour of the physical plant with Administrator Brandy 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 LPAs observed fire extinguishers throughout the facility, which were fully charged and last serviced 01/11/2023. The Administrator provided an annual fire alarm testing and inspection report done on 10/09/2023 where all smoke alarms and carbon monoxide detectors were tested and functioned properly. The LPAs observed all required postings in the hallways near the entrance area. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. Kitchen: During the facility tour, the kitchen appeared clean and the appliances and fixtures functional. The LPAs 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. Bedrooms: During today’s visit, the LPAs observed ten (10) randomly selected resident units. The resident bedrooms were properly furnished with at least one chair, nightstand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. At 10:32 a.m. the LPAs observed a Monday-Sunday medication dispenser filled with vitamins/medications, and cleaning disinfectants in RM 105. At 10:57 a.m. the LPAs observed Levothyroxine Sodium and Mupirocin 2% ointment in RM220. LPAs checked both residents Physicians Report (LIC602) that indicated the residents (R1, R2) cannot manage or store their own medications. 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: 10/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/18/2023 06:36 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: 10/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Request Denied

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. 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 as two out of ten resident rooms had disinfectants and or cleaning solutions which poses an immediate health and safety risk to persons in care.
	POC Due Date: 10/19/2023
	Plan of Correction
1 2 3 4	Administrator immediately removed the items from the rooms and agreed to submit a plan to CCL on how they will ensure all rooms don't have disinfectants and cleaning solutions by 10/19/23.

Type A

Section Cited

CCR

87355(e)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as two staff were not associated and one staff did not have a criminal record clearance, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 10/18/2023
	Plan of Correction
1 2 3 4	Administrator immediately associated the 2 staff and took the 1 staff without criminal record clearance off the schedule. POC is cleared during the visit.

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: 10/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/18/2023 06:36 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: 10/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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 as 2 out of ten resident rooms had medication not locked and accessible to residents who's physician report stated they could not store or administer their own medications, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 10/19/2023
	Plan of Correction
1 2 3 4	Plan of correction has been met during the visit. Administrator immediately removed the medications from the resident's rooms and agreed to keep them centrally stored or get an updated Physician's Report.

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: 10/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

LIC809 (FAS) - (06/04)

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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: 10/18/2023

NARRATIVE

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Bathrooms: The LPA observed all bathrooms, properly supplied and had functional fixtures. The LPA observed grab bars and non-skid mats in all bathrooms. Out of the ten (10) bathrooms observed, two (2) toilets required cleaning, and the flooring of one (1) bathroom was unclean. Upon observation, staff cleaned the areas. Water temperature measured in the restrooms ranged between 115.3 degrees Fahrenheit and 119.3 degrees Fahrenheit.
Common Areas: These included the beauty salon, library, chapel/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.
Infection Control: The community's policies and procedures pertaining to infection control were adequate.
Record Review: A review of facility files was initiated. LPA Olson reviewed five (5) of seventy-two (72) Staff files. Out of the five files reviewed, LPA Olson identified that two out of five staff (S1, S2) were not associated to the facility and one (1) out of five staff did not have a criminal record clearance. LPA Cortez reviewed five (5) out of ninety-three (93) resident files. All resident files reviewed were complete and accurate.
MEDICATION AUDIT: A medication audit for two (2) of five (5) residents was initiated and the following was observed. The medications were stored in the medication carts, which was locked and inaccessible to the clients. During both resident audits, the LPAs observed various medications not properly documented on the centrally stored medication and destruction log, as the quantity, expiration date and refills did not match the prescription labels. In addition, various medications did not have the start date documented on the centrally stored medication and destruction log. Staff documented the correct quantity, expiration dates, start date and refills upon observation.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights provided

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

LIC809 (FAS) - (06/04)

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