Palms At Bonaventure Assisted Living, The

Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to deliver investigation finding for the above noted allegations. Upon arrival LPA met with Executive Director (ED) Brandy McCauley and reason for the visit was explained. On 05/08/2025, Community Care Licensing Division (CCLD) received a complaint with the above allegations. Investigation was initiated by LPA Teresa Camara on 05/16/2025. LPA met with Administrator/Executive Director (ED) Brandy McCauley and the reason for the visit was explained. At 11:10 a.m. LPA Camara interviewed ED and obtained a copy of the resident roster. At 11:49 a.m. LPA Camara inspected restrooms near the dining room. On 08/16/2025, LPA Zabel Chochian conducted a subsequent complaint visit to further investigate allegations noted above. LPA Chochian met with the Activity Director John White and explained the reason for the visit. Executive Director (ED) Brandy McCauley was contacted and informed of LPA's visit. Copy of theRead the full finding— CDSS inspection report, September 26, 2025 · control 29-AS-20250508164959

Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint investigation visit. LPA met with Administrator Brandy McCauley and explained the reason for the visit. On 1/8/2025, LPA reviewed and obtained documents and interviewed three staff. During today's visit LPA interviewed ten (10) residents and three (3) more staff. Regarding the allegation staff are not following protocol for communicable disease: Residents who were interviewed that were present at the facility during a COVID outbreak stated residents were offered masks, all staff wore masks and gloves, and their cleaning protocols seemed sufficient. Staff stated they were given refresher training, and wore masks and gloves. The staff stated they would wear N95 masks, gowns, (continued on LIC9099-C, page 2) UnsubstantiatedRead the full finding— CDSS inspection report, May 7, 2025 · control 29-AS-20241230101400

Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint investigation with the purpose continuing the investigation related to the above noted allegations. LPA met with Administrator Brandy McCauley and explained the reason for the visit. During today's visit, LPA spoke with Administrator at 11:22AM, interviewed staff from 11:30AM to 02:31PM. During an initial complaint visit conducted on 12/30/2024, LPA interviewed Administrator at 11:00AM, interviewed the Memory Care Director at 11:15AM, toured the facility with Memory Care Director beginning at 11:52AM, interviewed resident's family member at 11:57AM, observed both Resident #1 (R1) and Resident #2 (R2), and LPA obtained copies of relevant documents. Throughout the course of the investigation, LPA reviewed all relevant documents and conducted additional interviews over the phone. The following was then determined: Report Continued on LIC 9099-C SubstantiatedRead the full finding— CDSS inspection report, April 3, 2025 · control 29-AS-20241223164716

Licensing Program Analyst (LPA) Teresa Camara conducted a complaint investigation visit regarding the above noted allegation. LPA met with administrator Brandy McCauley and explained the reason for the visit. At 12:53 p.m. LPA interviewed administrator, at 1:07 p.m. LPA interviewed the resident care director and at 1:57 p.m. LPA interviewed resident 1 (R1) by phone while at the facility. R1 confirmed the alleged perpetrator (P1) of the financial abuse was not an employee of this facility. P1 was someone R1 met through a nurse from an outside agency. P1 presented themself as an unemployed registered nurse who offered to help R1 with shopping and other personal assistance. R1 stated they (continued on LIC9099-C, page 2) UnsubstantiatedRead the full finding— CDSS inspection report, December 17, 2024 · control 29-AS-20241210133314

Licensing Program Analyst (LPA) Esther Cortez conducted a subsequent investigation visit to the facility regarding the above noted allegations. LPA met with executive director (ED) Brandy McCauley and explained the reason for the visit. On 02/06/2023 at 2:27 p.m. LPA Camera met with ED and resident care director Mary Ventura. Based on complaint allegations it was determined the complaint was regarding resident #1 (R1). At 3:08 p.m. LPA Camera reviewed and obtained pertinent records. At 3:14 p.m. LPA interviewed R1. On 12/14/2023 LPA Cortez obtained pertinent documents and conducted two (2) staff and one (1) resident interviews between 8:20 a.m. and 11:00 a.m. On 09/24/2024, between 10:30 a.m. and 4:30 p.m., LPA Cortez interviewed the ED, five (5) staff, conducted a file review, and obtained copies of resident records and other pertinent documents relevant to the investigation. During today's vist LPA Cortez observed seven (7) resident rooms, and conducted six (6) resident interviews. RRead the full finding— CDSS inspection report, September 25, 2024 · control 29-AS-20230202125108

Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to deliver findings for the above allegations. LPA met with Executive Director Brandy McCauley and explained the reason for the visit. On 04/10/2023, the Department received a complaint of Neglect/Lack of Care and Supervision alleging staff caused injury to Resident #1 (R1). It was alleged R1 sustained injuries while in care and the facility did not properly transfer R1. The complaint was referred to the Community Care Licensing Investigations Branch (IB) and assigned to Investigator Juan Lozano. On 04/12/2023, from 11:45 a.m. to 3:45 p.m., LPA Chochian conducted an unannounced complaint visit. The LPA reviewed facility incident reports for 2022-2023 and reviewed ten (10) resident records from 12:00 p.m. to 3:00 p.m. During the visit, the LPA was given a tour of the facility by staff Harmony Langarica. SubstantiatedRead the full finding— CDSS inspection report, May 13, 2024 · control 29-AS-20230410091906

Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced subsequent complaint visit for the allegation listed above. Due to Public Health concerns at the facility, today’s visit was conducted via telephone with the facility Executive Director (ED) Brandy McCauley. Entrance interview conducted. During an initial complaint visit conducted on 11/22/2023, at 09:36AM, LPA along with ED, toured the facility. LPA reviewed facility incident records for October - November 2023 and reviewed and obtained copies of pertinent documents. A referral was made to Community Care Licensing Division's (CCLD) Investigation Branch (IB). IB Investigator Dennis Seng then continued the investigation into the above allegation. Investigator Seng conducted both telephonic and in person interviews with relevant parties on the following dates: 12/13/2023, 12/14/2023, 02/16/2024. Throughout the course of the investigation, Investigator Seng reviewed medical records for Resident #1 (R1), who was named inRead the full finding— CDSS inspection report, April 29, 2024 · control 29-AS-20231121084529

Licensing Program Analyst (LPA) Esther Cortez conducted a subsequent complaint visit to deliver findings for the above allegation. The LPA met with Administrator Brandy McCauley and explained the reason for the visit. On 05/17/2021, LPA Rosales conducted the initial 10-day complaint visit from 11:25 AM – 6:00 PM, the LPA reviewed resident records, obtained copies of pertinent documents, and interviewed residents. LPA Smith conducted a subsequent complaint visit on 06/13/2023 from 9:45 AM – 2:30 PM, interviewed nine (9) staff, conducted a medication audit, and interviewed four (4) residents. On 10/03/2023, LPA Cortez toured the facility with administrator Brandy McCauley at 10:00 am, reviewed all staff and resident interviews conducted by LPA Rosales and Smith, and interviewed two (2) staff and two (2) residents between 10:20 a.m. and 11:30 a.m. Report will continue on LIC9099-C. UnsubstantiatedRead the full finding— CDSS inspection report, December 14, 2023 · control 29-AS-20210514112111

At 8:40 a.m. Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced subsequent complaint visit to the above facility to continue investigation of the above allegations. LPA met with Administrator Brandy McCauley and explained the purpose of the visit. LPA Rosales conducted the initial 10-day complaint visit on 05/17/2021 at 11:25 AM – 6:00 PM, the LPA reviewed resident records, obtained copies of pertinent documents and interviewed random residents. LPA Smith conducted a subsequent complaint visit on 06/13/2023 at 9:45 AM – 2:30 PM, interviewed nine (9) staff, conducted a medication audit, and interviewed four (4) residents. Today, LPA Cortez toured the facility with administrator Brandy McCauley at 10:00 am, reviewed all staff and resident interviews conducted by LPA Rosales and Smith, and interviewed two (2) staff and two (2) residents between 10:20 a.m. and 11:30 a.m. Report will continue on LIC9099-C. UnsubstantiatedRead the full finding— CDSS inspection report, October 3, 2023 · control 29-AS-20210514112111

Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct a subsequent complaint visit. The LPA met with Executive Director Brandy McCauley and explained the reason for the visit. On 05/24/2021, LPA’s Kelly Dulek and Martha Guzman-Chavez conducted an initial visit from 10:05 a.m. – 1:00 p.m., where they spoke with staff, conducted a tour, gathered documents, and conducted a medication audit. On 6/13/2023, LPA Smith interviewed nine (9) staff from 10:00 a.m. - 12:00 p.m., conducted a medication audit from 12:15 p.m. - 1:45 p.m., and interviewed four (4) residents from 1:50 p.m. - 2:30 p.m. Today, LPA Smith interviewed five (5) staff from 9:40 – 10:30 a.m., and interviewed three (3) residents from 10:35 a.m. – 11:20 a.m. UnsubstantiatedRead the full finding— CDSS inspection report, June 19, 2023 · control 29-AS-20210520121117

Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to deliver the findings for the above allegations. The LPA met with Executive Director Brandy McCauley and explained the reason for the visit. On 2/08/2022, LPA Joann Rosales conducted a visit from 11:00 a.m. – 4:30 p.m., in which LPA Rosales toured the facility, interviewed staff and residents, and obtained documents. On 02/28/2022, LPA Rosales conducted a subsequent visit from 10:55 a.m. – 4:10 p.m., in which LPA Rosales interviewed random residents and staff, and obtained additional documents. The allegation of ‘insufficient staffing’ alleges that the facility was understaffed in January and February of 2022, which resulted in staff being required to work with residents although staff were positive with COVID-19. Per interviews conducted by LPA Rosales on 2/8/2022 and 2/28/2022, staff revealed that a number of staff were requested to work, despite being symptomatic and COVID-19 positive. SubstantiatedRead the full finding— CDSS inspection report, May 22, 2023 · control 29-AS-20220201121402

Licensing Program Analyst (LPA) Ashley Smith conducted a subsequent complaint visit to deliver findings for the above allegation. LPA met with Brandy McCauley and explained the reason for the visit. Concerns were that due to neglect, resident #1 (R1) sustained pressure injury while in care. On 06/04/2021, LPA JoAnn Rosales conducted an initial visit from 10:10 a.m. – 5:00 p.m., to which LPA Rosales toured the facility, interviewed staff and residents, and obtained pertinent documents. LPA Rosales reviewed R1’s records on 6/4/21 starting at 11:39 am. R1’s service plan dated 4/28/21 indicated R1 needed assistance with their catheter including emptying the urine bag one time per shift and as needed if it was full, keeping the tubing clean each shift and not pulling on it to prevent injury, and to notify the charge nurse or medication technician if the catheter was leaking, or if the urine was dark in color or foul smelling. UnsubstantiatedRead the full finding— CDSS inspection report, May 19, 2023 · control 29-AS-20210603143418

Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent unannounced complaint visit regarding the above noted allegation. LPA met with Administrator/Executive Director Brandy McCauley, LVN and explained the reason for the visit. On 10/6/2022, the Department received this complaint alleging the facility did not properly manage resident’s personal belongings. Specifically, the allegation was Resident 1 (R1) had a bracelet stolen from their room. LPA conducted an initial complaint visit on 10/13/2022, interviewed the administrator and reviewed records. R1’s records showed they declined to have their personal items inventoried upon admission. It was also reported R1 had private caregivers during the day who stayed with R1 in their room and took R1 on errands. (continued on 9099-C) UnsubstantiatedRead the full finding— CDSS inspection report, April 21, 2023 · control 29-AS-20221006144842

Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced subsequent complaint inspection regarding the above allegations. The LPA met with Administrator Brandy McCauley at 10:45 AM and explained the reason for the inspection. On 03/05/2021, the complaint investigation began, although due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures the inspection was conducted virtually with the Administrator. During the visit, between 1:43 PM and 2:05 PM the LPA observed five residents rooms, rooms 124, 123, 103, 112, and 121 and the LPA requested pertinent records to be emailed. On 03/18/2022, the LPA conducted an in person inspection at the facility. During the inspection, the LPA conducted a physical plant tour with the Administrator beginning at 12:46 PM. Between 12:46 PM and 1:45 PM, the LPA observed four resident rooms in Assisted Living and four resident rooms in Memory Care. Report continued on LIC 9099-C. UnsubstantiRead the full finding— CDSS inspection report, February 17, 2023 · control 29-AS-20210226084535

Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced subsequent complaint inspection regarding the above allegations. The LPA met with Administrator Brandy McCauley at 10:45 AM and explained the reason for the inspection. On 03/05/2021, the complaint investigation began, although due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures the inspection was conducted virtually with the Administrator. During the visit, between 1:43 PM and 2:05 PM the LPA observed five residents rooms, rooms 124, 123, 103, 112, and 121 and the LPA requested pertinent records to be emailed. On 03/18/2022, the LPA conducted an in person inspection at the facility for another complaint investigation (complaint controls # 29-AS-20210226084535 and 29-AS-20200624150217) and also obtained information for this complaint investigation. Report continued on LIC 9099-C. UnsubstantiatedRead the full finding— CDSS inspection report, February 17, 2023 · control 29-AS-20210301124754