565802467-10-23-2024-29-AS-TCAA-DABV6X-20241023161017

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565802467
Report Date: 10/23/2024
Date Signed: 10/23/2024 04:11:02 PM

Document Has Been Signed on 10/23/2024 04:11 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:	10/23/2024
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	12:47 PM
MET WITH:	Brandy McCauley		TIME COMPLETED:	03:10 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	Licensing Program Analyst (LPA) Teresa Camara conducted a Case Management - Incident visit regarding two self-reported incidents at the facility. LPA met with administrator Brandy McCauley and explained the reason for the visit. At 12:56 p.m. LPA interviewed the administrator regarding the incidents. At 2:15 p.m. LPA interviewed the memory care director. At 2:28 p.m. LPA interviewed Staff 1 (S1). Starting at 1:05 p.m. LPA reviewed and obtained pertinent records. On 9/24/2024, Resident 1 (R1), who resides in a Memory Care apartment at the facility, eloped. R1 was noticed to be missing at 3:23 p.m. After searching and not locating R1, the police were called at 3:34 p.m. At 4:36 p.m. the police contacted the facility; R1 had been found at the mall by mall security. Staff went to pick R1 up at the mall and the resident was back at the facility at 5:00 p.m. According to the administrator, R1 was a new resident at the facility having just moved in on 9/17/2024. The facility was undergoing some remodeling and a carpet contractor was going in and out of the memory care unit. The contractor had the code for the door leading from assisted living to memory care in order to let themselves in and out without triggering the alarm. It appeared when the contractor opened the door they did not ensure the door fully latched behind them and that is how R1 was able to exit memory care without triggering the alarm. All memory care doors were tested and the alarms were functioning properly. (continued on LIC809C)

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024

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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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: 10/23/2024

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(continued from LIC809)

R1 had been an avid walker prior to moving into the facility. The administrator stated they are assuming R1 caught the bus which is right outside the facility and took it to the mall where R1 went shopping. When staff notified the police, the police alerted security at places like the mall and that is why mall security was on the lookout for R1 who returned to the facility unharmed.

S1 stated they had last seen R1 at approximately 3:10 p.m. when they escorted R1 to their room. There was an incident in memory care which required the attention of additional staff. After S1 assisted with that incident, at approximately 3:23 p.m., S1 went back to check on R1 and could not locate R1. S1 notified other staff and management R1 was missing and a search ensued.

Staff now take R1 on walks and they are conducting more frequent checks on R1. In addition, R1 has settled into the routine at the facility and has not been exit seeking. The memory care director indicated any changes in R1's behaviors will result in more frequent status checks.

The carpet is done in memory care. In the future, if contractors need to enter/exit the memory care unit they will need to be assisted by staff.

On 10/09/2024, Resident 2 (R2) had an unwitnessed fall in their room. R2 used their pendant to call for assistance. Staff found R2 on the floor and due to pain R2 was unable to move. Staff called 9-1-1 and R2 was taken to the hospital where they were diagnosed with a fractured wrist, femur, hip and back. R2 is currently in a skilled nursing facility receiving rehabilitation.

At 1:05 p.m. LPA reviewed records for R2. R2 resides in an Assisted Living apartment at the facility. The physician's report for R2 indicated R2 was ambulatory. The only services R2 receives at the facility are laundry and medication management. R2 is otherwise considered independent with ambulating and does not require any transfer assistance. R2 does not normally use a walker or cane.

Based on interviews and records reviewed, there were no deficiencies observed at this time. Exit interview conducted and report issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024

LIC809 (FAS) - (06/04)

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