565802467-9-25-2024-29-AS-KLOZ-D9J3K9-20240927181847

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802467
Report Date: 09/25/2024
Date Signed: 09/25/2024 05:07:19 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
02/02/2023 and conducted by Evaluator Esther Cortez

COMPLAINT CONTROL NUMBER: 29-AS-20230202125108

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: 83	DATE:	09/25/2024
		UNANNOUNCED	TIME BEGAN:	02:05 PM
MET WITH:	Brandy Mccauley		TIME COMPLETED:	05:10 PM

ALLEGATION(S):

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Resident sustained pressure injuries while in care.
Staff leaves resident in bed for extended periods of time.
Staff does not ensure resident is fed or is provided water.
Staff leaves resident without light.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Esther Cortez conducted a subsequent investigation visit to the facility regarding the above noted allegations. LPA met with executive director (ED) Brandy McCauley and explained the reason for the visit.

On 02/06/2023 at 2:27 p.m. LPA Camera met with ED and resident care director Mary Ventura. Based on complaint allegations it was determined the complaint was regarding resident #1 (R1). At 3:08 p.m. LPA Camera reviewed and obtained pertinent records. At 3:14 p.m. LPA interviewed R1. On 12/14/2023 LPA Cortez obtained pertinent documents and conducted two (2) staff and one (1) resident interviews between 8:20 a.m. and 11:00 a.m. On 09/24/2024, between 10:30 a.m. and 4:30 p.m., LPA Cortez interviewed the ED, five (5) staff, conducted a file review, and obtained copies of resident records and other pertinent documents relevant to the investigation. During today's vist LPA Cortez observed seven (7) resident rooms, and conducted six (6) resident interviews. Report will continue on LIC9099-C (2nd page).

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024

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 4

Control Number 29-AS-20230202125108

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/25/2024

NARRATIVE

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On the allegation, "Resident sustained pressure injuries while in care", on February of 2023, the reporting party (RP) reported that Resident #1 (R1) sustained pressure wounds on their bottom that took approximately 1.5 weeks to close. Dates of when R1 sustained pressure wounds were not disclosed. To investigate the allegation LPA Cortez conducted a file review and interviews. File review revealed that R1 was admitted to Palms of Bonaventure on 10/20/2021, R1’s Physician’s report dated 08/26/21 indicated that R1 had a history of skin condition or breakdown. R1’s Service Plan dated 11/08/2021 revealed that R1 had no current skin issues, history of stage one to the buttocks, uses air loss mattress and needed to be turned and repositioned approximately every 2 hours at night. R1’s subsequent care evaluation dated 10/11/2022, revealed that R1 had no current skin issues, and no wounds were noted. Furthermore, files reviewed revealed that on 10/21/2022, staff informed R1’s physician that R1 was presenting redness/irritation to their buttocks area and requested a prescription for A&D or Balmex and R1 was prescribed A&D ointment. On 01/18/2023, staff informed R1’s physician that R1 had a breakdown to R buttock, they applied barrier cream, resident was only up for meals and turned every two (2) hours, to which R1’s physician acknowledge, however no new orders were given. Staff interviews revealed that R1, had poor skin integrity, had skin breakdowns on their buttock, however they do not recall if R1 had any staged pressure injuries. Staff revealed that R1 would be repositioned every two (2) hours and when R1 would present any redness or breakdown, they would inform R1’s physician. R1’s physician would prescribe medication or come to the see R1 if they deemed it was warranted. Lastly, LPA Cortez did not observe any diagnosis of staged pressure injuries on R1’s buttocks in R1’s file. 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 “Resident sustained pressure injuries while in care” is deemed unsubstantiated at this time.

Report will continue on LIC9099-C 3rd page.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 29-AS-20230202125108

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/25/2024

NARRATIVE

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On the allegations, “staff leaves resident in bed for extended periods of time, staff does not ensure resident is fed or is provided water, and staff leaves resident without light”, on February of 2023 the RP reported that on Jan. 25, 31, and Feb.1, R1 was in their bed between 4-5 p.m. instead of in their reclining chair and their dinner was left by the door. It was further reported that R1’s lights were often off, and R1 was left with no access to food, water, and light. To investigate the allegations LPA Cortez and LPA Camera conducted interviews, file review and a tour of R1’s room.

Interview with R1, on 02/06/2023 conducted by LPA Camara in R1’s room revealed that R1 liked the facility, got enough food to eat and liked the food. R1 recalled that one day staff forgot to turn their light on but was fixed, and R1 had no complaints about the facility. During the interview, LPA Camera observed R1 in their recliner chair at 3:14 p.m. and observed a nearly empty glass of lemonade.

Staff interviews revealed that R1 would normally be up (in their wheelchair) during the day for meals and activities. However, when R1 experienced skin breakdown on their bottom, they would be in their bed, rotated every 2 hours, and staff would either transfer R1 to their recliner for meals, or sit them up to eat in bed if R1 preferred being in bed. File review and staff interview revealed that on 01/18/2023, R1 was experiencing a breakdown to R buttock, staff informed R1’s physician they applied barrier cream, resident was only up for meals and turned every two (2) hours, to which R1’s physician acknowledge, however no new orders were given. Staff revealed that when residents have redness, irritation, skin breakdown, bed sores, wounds, or pressure injuries on their bottom, it’s standard for them to be in their bed and rotated every 2 hours, and only up for meals to relieve pressure from sitting down and allow their skin to heal.

Staff interviews revealed that R1 would eat at the dinning room, and only receive meal trays in their room when they were sick. Staff further revealed that, meals are always left where residents can reach, and depending on the resident, if needed they would assist residents in opening food items. Staff stated the only reason that a resident would be left without eating is if they refused, however meals and water are always provided. Staff further revealed that they would transfer R1 to their recliner and place R1’s meals in R1’s side table next to them and R1 would eat on their own. Or they would sit R1 up on their bed and place the meals on their side table. Staff denied leaving meals where residents cannot reach.

Report will continue on LIC9099-C 4th page.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 29-AS-20230202125108

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/25/2024

NARRATIVE

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During today’s visit, between 2:50 p.m. to 4:30 p.m. LPA Cortez observed seven (7) resident rooms including R1’s previous room (between 4:10 p.m. and 4:30 p.m.) and observed enough light coming through the windows without the light needing to be turned on. Staff interviews revealed that they have never observed any resident in their room without any light, and that staff would open R1’s curtains in the morning and later would turn on the lights. Furthermore, staff revealed that staff was often coming in and out of R1’s room to provide care and they would turn on the lights if needed. Additionally, six (6) residents out of six residents interviewed today revealed that they have never been left without food, water, or lights. Resident interviews revealed that staff turn on the lights for them if they have not turned them on themselves. Three (3) out of three (3) residents that get their meals delivered to them revealed that staff have never placed their meals where they cannot reach them.

Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violations occurred; therefore, the allegations “Staff leaves resident in bed for extended periods of time, staff does not ensure resident is fed or is provided water, staff leaves resident without light are deemed unsubstantiated at this time.

Exit interview conducted. A copy of the report provided

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 4