<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802467
Report Date: 03/14/2023
Date Signed: 03/14/2023 04:08:15 PM


Document Has Been Signed on 03/14/2023 04:08 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: 94DATE:
03/14/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Brandy McCauleyTIME COMPLETED:
04:10 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 Analysts (LPAs) Martha Arroyo and Esther Cortez conducted an unannounced Case Management – Incident visit to the above facility. The LPAs met with Executive Director, Brandy McCauley and explained the reason for the visit. Entrance interview.

On 03/09/2023, the Department received a Special Incident Report regarding Resident #1 (R1). The report stated that R1’s roommate alerted staff R1 was on their bed bleeding from a fall. Staff observed R1 on top of bed bleeding from right temple area on their face. R1 was unable to recall how incident occurred. R1’s roommate stated they were standing at the end of bed talking when R1 turned to walk away, R1’s feet got tangled causing R1 to fall.

During today’s visit, the LPA’s interviewed the Executive Director at 4:00pm and requested documents pertinent to the investigation. This incident was referred to Community Care Licensing Investigations Branch (IB) and assigned to IB Investigator Christine Ferris.

Further investigation is required prior to issuing findings. No health and safety concerns noted at this time. Exit interview conducted. A copy of the report was issued to the Executive Director.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2023
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 1