The Palms at Bonaventure

Allegation investigated: Staff are not following residents’ special diet. Staff are not safeguarding the residents’ personal belongings. Staff is retaliating against resident. Facility does not have sufficient staff to meet the needs of residents in care.

On 05/07/2026, Licensing Program Analyst (LPA) Jeffries arrived unannounced at the facility to issue final findings to the allegations to this complaint, as well as this facility annual inspection on a separate report.. LPA noted that this visit included issuing final findings to all allegation of a separate complaint (29-AS-20251024145127) at the same facility location under a different Community Care Licensing (CCL) facility file number (565802467) that is was closed on 06/13/2025 and last updated on 10/28/2025. LPA met with Administrator, Brandy McCauley, announced who he is and the reason for the visit. As to the allegation of, “Staff are not following residents’ special diet.” It was alleged that facility continues to feed the resident (R1) pasta, potatoes and bread. And, R1 had asked for a cheeseburger with no bun and the staff told him they don't know how to use the new stove to cook him a cheeseburger. On 10/23/2025 Licensing Program Analyst (LPA) Emily Peraldi conducted interviews with Staff 1-6 (S1, S2, S3, S4, S5, and S6). All staff stated that residents with a modified diet are facilitated with a modified diet on a daily basis. On 10/23/2025, CONTINUED on LIC9099-C Unsubstantiated LPA Peraldi conducted an interview with facility Executive Director (ED), Brandy McCauley, who stated that R1 was determined by his physician to be capable of managing their own medications and diet. ED stated that R1 “mostly follows (R1’s) special diet but once in a blue moon R1 has crackers and cookies. ED stated they have communication with his doctor.” On 03/20/2026, LPA Mark Jeffries conducted interviews with Residents 1-6 (R1, R2, R3, R4, R5, and R6). R1 stated that the facility is good about providing restrictive diet menus. R1 stated that the facility community activities there are prizes that consist of candy, and the facility does provide sugar free candy, but sometime R1 likes to eat the regular candy as well. R1 stated that occasionally R1 will eat menu choices that are not part of the special diet by choice. R2, R3, R4, R5, and R6 all stated, “facility is good about menu choices. And facility is good at providing special diets that are needed for residents. On 03/20/2026, LPA conducted an interview with facility Chief (S6) S6 demonstrated to LPA how special diets are identified in the facility kitchen so that the staff deliver special diets to residents that have special dietary needs, and requirements. Residents that are identified with special diets are posted on the kitchen wall with the resident’s name and what special diet is identified to a specific resident. S6 stated that these special diets are always available and presented to the residents that are identified. S6 stated that if those residents request additional food items or off the menu items they are provided with and the care staff is notified that the special diet was not followed. Based on documentation of special diet screening, interviews of resident stating availability of special diets provided by the facility, and interviews of residents exercising specific dietary choices, there is not enough evidence at this time to support the allegation of, “Staff are not following the residents’’ special diet.” and is unsubstantiated at this time. As to the allegation of, “Staff are not safeguarding the residents’ personal belongings.” and “Staff is retaliating against residents.” It was alleged that R1 lost 3 sets of pajamas in laundry and staff were retaliating against R1 due to not returning R1’s pajamas from laundry and not properly folding cleaned laundry. On 10/23/2025 LPA Peraldi conducted interviews with S1 - S6, all staff stated that there were no concerns regarding residents’ items being safeguarded by facility. S3 stated that, “Sometimes laundry gets mixed up and they check other rooms and linen closet. Usually, missing items are found.” However, R1’s missing items were never found over one year ago. On 03/20/2026, LPA Jeffries conducted interviews with R1-R6, R1 stated that the there was only one set of pajamas that were lost and, “never found or maybe I misplaced them.” R1 also stated that they have no issue with facility safeguarding personal property. R2-R6 all stated that they had no issues with facility safeguarding residents’ property. CONTINUE on LIC9099-C On 10/23/2025 LPA Peraldi conducted an interview with ED who stated, “staff have been trained on resident’s personal rights. She said they use Relias training. She said residents’ personal rights are posted on the wall. She said staff wouldn’t retaliate against residents. She said staff are loving and they know about personal rights.” On 03/20/2026, LPA Jeffries reviewed care giver training records for the facility and noted that all caregivers had current “Residents Personal Rights” training through Relias training program. Based on interviews, and records review, at this time there is not enough evidence to support the allegation of, “Staff are not safeguarding the residents’ personal belongings.” and “Staff is retaliating against residents.” and both are unsubstantiated at this time. As to the allegation of, “Facility does not have sufficient staff to meet the needs of residents in care.” It was alleged that staff are getting fired or leaving and there are no staff available for R1. On 10/23/2025 LPA Peraldi conducted an interview with ED who stated, “that they have enough staff to meet needs. She said there are no staff concerns or staffing shortage. In Memory Care (MC) there are three (3) caregivers and three (3) in Assisted Living (AL). She said there are medication technician (med-techs) on each shift.” On 10/23/2025 LPA Peraldi conducted interviews with S1-S6, all stated no concerns with staffing ratios. On 03/20/2026, LPA Jeffries conducted interviews with R1-R6. All stated they had no issues with staffing to resident ratios. R1 – R6 all stated that their needs are met on a daily basis and have no concerns. R1 stated that staff do a great job attending to (R1’s) needs. LPA Jeffries reviewed current facility staff schedules which showed care giver coverage that reflected staff converge in staff and resident interviews. At this time there is not enough evidence to support the allegation of, “Facility does not have sufficient staff to meet the residents needs.” and is unsubstantiated at this time. Exit interview, report read, and report provided.the state’s words, verbatim · CDSS document, May 7, 2026 · control 29-AS-20251015104115

Type of visit: Required - 1 Year

On 05/07/2026, Licensing Program Analyst (LPA) Jeffries arrived unannounced at the facility to conduct facility annual inspection, as well as issue final findings to the allegations to a complaint on a separate report. LPA noted that an additional finial finding to allegation of a separate complaint (29-AS-20251024145127) at the same facility location under a different Community Care Licensing (CCL) facility file number (565802467) that is was closed on 06/13/2025 and last updated on 10/28/2025. LPA met with Administrator, Brandy McCauley, announced who he is and the reason for the visit. The facility is two story and has one elevator. LPA conducted physical plant tour inside and out of the facility. LPA noted fire clearance 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 residents’ rooms have direct exits outside. There is a large dining room and industrial type kitchen located on the first floor and there are medication rooms on both the first floor and second floor where mediations are stored in medication carts and fist aide kits are stored. 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 non-private bathrooms. There is a screened fireplace located in assisted living adjacent to the large dining room. 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. CONTINUED on LIC809-C The facility smoke alarm system is hard wired. Facility has carbon monoxide detectors in common areas. The carbon monoxide detectors are tested by maintenance staff monthly. 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. Fire extinguishers are inspected by maintenance and annually by an approved vendor with the last annual inspection having been completed on 4/10/2025. Administrator stated that the next vender fire inspection is scheduled for May of 2026 pending bid approval. Administrator and LPA conducted a full physical tour of the facility and grounds and there were no violations noted. Administrator and LPA conducted a full review of the care tools modules and noted no violations or citations noted. LPA conducted file review of Resident and Staff files, Emergency Disaster Plan, Infection Control Plan, Centrally Stored Medication Records, Medication Administration Records, and Facility Liability Insurance coverage. LPA noted not violation and no citations during this full annual inspection. Exit interview, report read and report provided.the state’s words, verbatim · CDSS document, May 7, 2026

Allegation investigated: Staff do not maintain facility sanitary Staff did not provide a safe environment for resident

Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced subsequent complaint visit at this facility today. At 01:30PM, the LPA met with facility staff and explained the reason for the visit. Facility staff indicated Executive Director is not available for today’s visit. At 01:35PM, LPA met with Harmony Langarica, Senior Business Office Director. Entrance interview conducted. On 10/20/2025, the Department received a complaint for the above allegations, however, the complaint was created under the incorrect license number. The complaint is regarding allegations from December 2024. The facility underwent a change of ownership and a new license was issued on 05/25/2025. A new complaint has since been generated under the correct license number. During the initial visit conducted on 10/23/2025 between 9:40 a.m. and 2:05 p.m., LPA Emily Peraldi conducted a physical plant tour and interviews with the ED, and six (6) staff. LPA Peraldi also obtained copies of pertinent documents. Based on the information obtained, the above allegations are deemed Unfounded at this time. A finding of unfounded means that the allegation is either false, could not have happened, and/or is without a reasonable basis. Exit interview conducted. A copy of the report was provided. Unfoundedthe state’s words, verbatim · CDSS document, Oct 27, 2025 · control 29-AS-20251020120807

Allegation investigated: Facility does not have sufficient staff to meet the needs of residents in care

Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint investigation visit. LPA met with Executive Director (ED) Brandy McCauley and explained the reason for the visit. On 6/6/2025, LPA Mosley conducted the initial complaint investigation visit. During that visit LPA Mosley interviewed ten (10) residents who all stated their care needs were met by staff and they had no complaints about the care they were receiving. LPA Mosely interviewed three (3) staff and the ED during that visit. Staff stated when other staff call out staffing can be short, but they still meet the needs of the residents. The ED stated when they have staff unexpectedly call out, they ask on-call staff to take the shift. If on-call staff are not available, they will ask other staff to stay late or come in early or one of the management team step in to assist. (continued on LIC9099C) Unsubstantiated (continued from LIC9099) During today’s visit, LPA Camara obtained pertinent documents and interviewed the Resident Care Coordinator (RCC) at 10:50 a.m. and the ED at 10:30 a.m. Both stated they have procedures for meeting staffing needs. If they still are unable to find staff to fill spots, the ED will get agency staff to cover, but they have not needed agency staff in about a year because they are able to cover call outs. LPA reviewed the schedules for both assisted living and memory care. In assisted living the facility typically schedules four caregivers and two medication technicians on the morning shift (6:00 a.m. - 2:00 p.m.) and the afternoon shift (2:00 p.m. - 10:00 p.m. The overnight shift (10:00 p.m. - 6:00 a.m.) (NOC shift) typically has two caregivers and one medication technician. The memory care typically has three or four caregivers and a medication technician during the morning and afternoon shifts and one caregiver and one medication technician during the NOC shift. Based on interviews and records reviewed, the allegation “Facility does not have sufficient staff to meet the needs of residents in care” is deemed UNSUBSTANTIATED at this time. The ED was unavailable to sign this report. The Business Office Director Harmony Langarica signed on the ED's behalf. No citations issued. Exit interview conducted and report issued.the state’s words, verbatim · CDSS document, Jul 9, 2025 · control 29-AS-20250602093028

Type of visit: Prelicensing

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) (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) (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.the state’s words, verbatim · CDSS document, May 16, 2025

Type of visit: Office

Facility Type: Residential Care Facility for the Elderly Application Type: Initial Capacity: 121 Census (if any clients in care): 96 COMP II Participants: BRANDY MCCAULEY, ALAN SPRAGINS Interview Method: Telephone interview On April 29, 2025, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restricted/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Apr 29, 2025