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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802467
Report Date: 02/08/2022
Date Signed: 02/08/2022 04:18:46 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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, THEFACILITY NUMBER:
565802467
ADMINISTRATOR:MCCAULEY, BRANDYFACILITY TYPE:
740
ADDRESS:111 N WELLS ROADTELEPHONE:
(805) 647-0616
CITY:VENTURASTATE: CAZIP CODE:
93004
CAPACITY:121CENSUS: 94DATE:
02/08/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Brandy McCauleyTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) JoAnn Rosales conducted a Case Management - Deficiencies visit at the facility. LPA met with Administrator Brandy McCauley.

During facility tour with Administrator at 11:15 am LPA observed Fabric Conditioner, Enviro-Coil cleaner, Oasis Multi-Quat Sanitizer/Disinfectant/Deodorizer, Oasis Orange Force Multi-Surface Cleanser in 1st floor Laundry Room accessible to residents. During facility tour with Administrator at 11:21 am LPA observed Apple Cinnamon Diffuser refill and Concentrated Laundry Fresh Air Freshener in Memory Care kitchen accessible to residents. At 11:50 am LPA observed a lighter in back area patio accessible to residents.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).

Civil Penalty assessed in the amount of $250.00.

Exit interview was conducted, today's reports, civil penalty and appeal rights were reviewed and emailed to the Administrator.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2022
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
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: 02/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/18/2022
Section Cited

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87705 Care of Persons with Dementia(f)(1) The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
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Based on LPA's observations and record review, the licensee did not comply with the section cited above as a lighter was observed accessible to residents which posed an immediate safety risk to persons in care.
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Type A
02/09/2022
Section Cited

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87705 Care of Persons with Dementia (f)(2) The following shall be stored inaccessible to residents with dementia: 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:
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Based on LPA's observations and record review, the licensee did not comply with the section cited above as toxic substances were observed accessible to residents which posed an immediate health risk to persons 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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2022
LIC809 (FAS) - (06/04)
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