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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850615
Report Date: 05/16/2025
Date Signed: 05/16/2025 03:09:29 PM

Document Has Been Signed on 05/16/2025 03:09 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, THEFACILITY NUMBER:
565850615
ADMINISTRATOR/
DIRECTOR:		MCCAULEY,BRANDYFACILITY TYPE:
740
ADDRESS:111 NORTH WELLS ROADTELEPHONE:
(805) 647-0616
CITY:VENTURASTATE: CAZIP CODE:
93004
CAPACITY: 121CENSUS: 105DATE:
05/16/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Brandy McCauley, LVNTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Teresa Camara conducted a pre-licensing visit to the above noted facility. The LPA met with administrator/executive director (ED) Brandy McCauley, LVN. This facility is currently operating under a different license and this is a change of ownership application. A dementia program was included in the plan of operation. A Hospice Waiver has been requested. At 9:38 a.m. LPA completed the Component III with the ED.

The facility is two-story and has one elevator. At 10:15 a.m. a physical plant tour was conducted inside and out. An approved fire clearance was received, clearing them for 121 non-ambulatory residents and delayed egress is approved for the memory care unit. The facility has ninety (90) private resident bedrooms and fourteen (14) shared rooms. Some shared rooms may be used as private rooms. None of the resident's rooms have direct exits outside. The residents choose to bring their own furniture. LPA inspected eleven (11) resident rooms. All were appropriately furnished with beds, clean linens, nightstands, lamps, chests of drawers, chairs and closet space. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. Rooms were free of odors. Window screens were clean. The rooms were maintained in good repair.

(continued on LIC809-C, page 2)

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Teresa Camara
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2025
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 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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, THE
FACILITY NUMBER: 565850615
VISIT DATE: 05/16/2025
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(continued from LIC809, page 1)

All resident rooms have private bathrooms. The hot water temperature was tested in four (4) resident bathrooms and was found to be within the required range of 105*F and 120*F. There are a total of six restrooms open to the public. All bathrooms were observed to be cleaned and stocked with toilet paper, towels and soap. All bathrooms were equipped with grab bars next to the toilet and in the showers. All showers had non-skid surfaces.

There are no sleeping quarters for staff. All three shifts (am, pm, night) have awake staff only.

Resident and staff records are stored in medication rooms and business office. Medications are centrally stored in medication carts in the locked medication rooms. The first aid supplies are stored in the medication rooms.

The facility has a commercial kitchen which is not accessible to residents. Knives are stored in the kitchen. The supply of dishes, utensils, pots, pans and drinkware is adequate. The walk-in freezer was maintained at -2 degrees Fahrenheit (-2*F), the walk-in refrigerator was maintained at 33 degrees Fahrenheit (33*F) and the other refrigerator was maintained at 37 degrees Fahrenheit (37*F). The supply of perishable and nonperishable food is adequate. A supply of emergency water is kept in a garage. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional. Trash cans had tight fitting lids. No flies or signs of other vermin were observed.

The common areas were appropriately furnished, and the lighting was adequate. There are activity rooms and television rooms with comfortable seating in assisted living and memory care. There was sufficient space to accommodate both indoor and outdoor activities. Night lights and emergency lighting were maintained in hallways and passageways to nonprivate bathrooms. There is a screened fireplace located in assisted living adjacent to the large dining room. The delayed egress doors in memory care are tested weekly. The physical plant is consistent with the submitted facility sketch/floor plan. The facility has a furnace, which is able to heat rooms that residents occupy to a minimum of 68 degrees Fahrenheit; and, they have central air conditioning and are able to cool rooms to a comfortable range, not to exceed 85 degrees Fahrenheit.

(continued on LIC809-C, page 3)
NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Teresa Camara
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
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, THE
FACILITY NUMBER: 565850615
VISIT DATE: 05/16/2025
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(continued from LIC809-C, page 2)

The facility smoke alarm system is hard wired. They have carbon monoxide detectors in common areas. The carbon monoxide detectors are tested by maintenance staff weekly. The fire sprinkler system, smoke alarm and fire doors were last inspected 4/16/2025 by fire marshal approved vendors. Maintenance checks smoke alarms and sprinkler systems monthly and weekly. Fire extinguishers are inspected by maintenance and annually by an approved vendor with the last annual inspection having been completed on 4/10/2025. Emergency evacuation drills are conducted on all shifts monthly.

There is a functioning telephone on the premises. The emergency exiting plans/sketch are posted. Emergency telephone numbers are posted in the medication room. Other required postings were observed.

The exterior passageways were clean and clear of any obstructions. There is a fenced outdoor area with a covered patio for memory care residents. There is a covered patio and outdoor area for assisted living residents. There are no bodies of water on the premises. There is a garage used for storage which remains locked at all times. Maintenance keeps their tools stored in the locked garage. The garage is a stand alone building and not physically connected to the facility.

There were no deficiencies observed during this pre-licensing visit.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating under the new license until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.
NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Teresa Camara
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2025
LIC809 (FAS) - (06/04)
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