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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802467
Report Date: 02/28/2022
Date Signed: 02/28/2022 04:06:54 PM


Document Has Been Signed on 02/28/2022 04:06 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
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: 96DATE:
02/28/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Brandy McCauleyTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) JoAnn Rosales conducted an unannounced Case Management - Incident visit at the facility today to follow up on an incident report pertaining resident #1 (R1). On 2/12/22 R1 was observed at The Bonaventure Independent Living facility which is next door to the facility. Staff #1 (S1) went to the facility next door and escorted R1 back to the facility. R1 did not sustain any injuries related to the incident. R1's family member was notified and and agreed to move R1 to memory care due to R1's confusion and elopement risk.

During today's visit LPA toured the facility with the Administrator. Administrator stated that R1 was last seen in the dining room for dinner on 2/12/22. Administrator stated that during the weekends they do not have anyone at the front desk. Administrator stated that R1 was moved into memory care the evening of the incident on 2/12/22. Based on interviews and a review of R1's records on 2/25/22 at 1:00 pm LPA observed that R1 is not able to leave the facility unassisted.

During facility tour on 2/28/22 starting at 11:01 AM with Administrator Brandy McCauley LPA observed that staff #1 (S1), S2 and S3 are working at the facility and are fingerprint cleared and not associated to the facility. Administrator stated that S1 started working with residents today. S2 worked at the facility on 2/7, 2/8, 2/9, 2/10, 2/14, 2/15, 2/16, 2/17, 2/19, 2/20, 2/21, 2/22, 2/23, 2/27 and 2/28/22. S3 worked at the facility on 2/1, 2/2, 2/3, 2/4, 2/6, 2/7, 2/10, 2/11, 2/12, 2/13, 2/14, 2/15, 2/17, 2/18, 2/22, 2/23, 2/24, 2/25, 2/26 and 2/28/22. Administrator stated that S2 and S3 are not their staff and that they work for a Home Care Agency named Genie Home Care Staffing Agency.

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

Continued on 809C
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2022
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 3


Document Has Been Signed on 02/28/2022 04:06 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
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: 02/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/28/2022
Section Cited

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87464 Basic services (f)(1)(c) Basic services shall at a minimum include: Care and supervision as defined… Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living…
This requirement is not met as evidenced by:
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Based on interviews and record review, the licensee did not comply with the section cited above as R1 left the facility unassisted which posed an immediate health and safety risk to persons in care.

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Type A
02/28/2022
Section Cited

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87355 Criminal Record Clearance. (e)(2) 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: Request a transfer of a criminal record clearance as specified in Section 87355(c) or...
This requirement is not met as evidenced by:
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Based on interviews, the licensee did not comply with the section cited above as the licensee did not ensure that S1, S2 and S3 were associated prior to allowing S1, S2 and S3 to work which poses an immediate safety 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: 02/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


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
VISIT DATE: 02/28/2022
NARRATIVE
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Civil penalties assessed in the amount of $3,600.00.

Exit interview conducted, today's reports, appeal rights and civil penalty 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: 02/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3