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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802467
Report Date: 10/18/2022
Date Signed: 10/18/2022 11:45:47 AM


Document Has Been Signed on 10/18/2022 11:45 AM - 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:
10/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:49 AM
MET WITH:Brandy McCauley, AdministratorTIME COMPLETED:
12:00 PM
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On 10/18/22 at 9:49 am, Licensing Program Analyst (LPA) Chavez conducted an unannounced on-site annual infection control visit to the facility above. LPA met with Brandy McCauley, Administrator, and explained the purpose of the visit.

LPA toured the facility with the administrator and observed the following: The facility has infection control signage at the front door and signage throughout the facility on handwashing and use of masks. Cough etiquette signage was not visible, and Administrator states they recently removed signage due to deterioration. Administrator has committed to replacing the signage and will send a photo to CCL by 10/19/22. Upon entry to the facility, LPA was not screened. There is a table at the reception area with a thermometer, hand sanitizer and visitor sign-in sheet. Administrator will ensure that staff assisting visitors at the lobby are trained to screen visitors upon entry and send the training sign-in sheet to CCL by 10/19/22. Staff are wearing masks. Resident rooms have their own bathrooms with soap dispensers and paper towel dispensers. More than seven fire extinguishers are located throughout the facility. Extinguishers are fully charged and were inspected on 4/06/22. At 9:58 am, LPA observed six uncovered, unlabeled ice cream in bowls in the freezer and ten unlabeled parfait in bowls, an unlabeled container of yellow squash, and unlabeled ground meat in the refrigerator. Administrator will ensure kitchen staff are trained on proper food storage and send a copy of the training sign-in sheet to CCL by 10/25/22. The facility has a CCLD Complaint poster, however, it is an 8.5”x11”. Regulation is a 20”x26” complaint poster. Administrator will post a regulation size poster and send a photo to CCL by 10/25/22. At 10:43 am, LPA observed two areas of the facility’s fence that were damaged due to fallen trees. Administrator has committed to replacing the fences and will send the estimate(s) for repair to CCL by 10/25/22.

At 10:57 am, LPA conducted the Infection Control mitigation module with the licensee. No deficiencies cited.

Exit interview conducted and report emailed to the administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2022
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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