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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850615
Report Date: 09/15/2026
Date Signed: 09/15/2026 11:55:17 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/01/2026 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20260501144101
FACILITY NAME:PALMS AT BONAVENTURE, THEFACILITY NUMBER:
565850615
ADMINISTRATOR:MCCAULEY,BRANDYFACILITY TYPE:
740
ADDRESS:111 NORTH WELLS ROADTELEPHONE:
(805) 647-0616
CITY:VENTURASTATE: CAZIP CODE:
93004
CAPACITY:121CENSUS: 103DATE:
09/15/2026
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Brandy McCauleyTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff handled resident roughly

Staff did not notify authorized representative of an unusual incident with resident

Staff falsified documents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced subsequent complaint visit to deliver final findings of the allegations listed above. Upon arrival LPA met with Executive Director Brandy McCauley and explained the reason for the visit.

On 05/06/2026, LPA conducted an initial 10-day complaint visit to investigate the allegations listed above. At approximately 10:00 a.m. LPA conducted physical plant tour, interviewed staff and residents, obtained and reviewed Safely U Footage as well as obtained copies of pertinent documentation relevant to the investigation. On 08/21/2026, LPA conducted a subsequent complaint visit to continue investigation on the allegations listed above. At approx. 10:05 a.m. LPA conducted physical plant tour, interviewed staff, residents, families / responsible parties, as well as reviewed and obtained additional copies of pertinent documentation relevant to the investigation. On 09/01/2026, LPA reviewed additional records obtained from the facility.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 29-AS-20260501144101
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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, THE
FACILITY NUMBER: 565850615
VISIT DATE: 09/15/2026
NARRATIVE
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Continued from 9099

It was reported that "Staff handled resident roughly" as it was alleged that Staff #1(S1) forcibly removed clothing on Resident #1 (R1) by yanking on garments, then physically redirected R1 when they resisted. Safely U video footage obtained and reviewed of the incident reflected that on 04/24/2026, S1 was assisting R1 with changing clothes in R1’s room, during which S1 repeatedly held and controlled R1’s wrist or arm as R1 attempted to walk away, including gripping both hands around R1’s left wrist, redirecting R1 by pulling the wrist and maintaining physical control despite R1’s hesitancy. Additionally, video footage reflected S1 attempts to remove R1’s pants in spite of R1’s reluctance, during which R1 loses balance and falls backward onto the couch. S1 is then seeing turning around to grab R1’s pants from the sofa, while R1 stands up. S1 then pushes R1 down on to the couch to put on R1’s pants on. Once fully clothed, R1 attempts to walk past S1 towards the entry way, S1 then steps in front of R1 attempting to redirect R1 towards the sofa/recliner even though R1 appears to be unwilling. During the interaction, R1 falls to the floor while S1 is holding on to R1’s wrist. S1 then continues to pull R1 by their wrist towards the recliner. Following the fall, S1 attempts to lift R1 from the floor, first pulling R1 by the upper left arm and then wrapping their arms around R1’s back. S1 is then visible calling for assistance using a walkie talkie.
Interviews conducted and records reviewed further reflected that S1 was suspended following the incident and no longer is employed by the facility. On 04/28/2026, the community conducted an immediate in-service training on topics including but not limited to challenging behaviors in residents, redirection techniques, sundowning, and appropriate responses to resistant or combative behaviors. Based on the information obtained during the investigation, the Department has sufficient evidence to confirm this allegation occurred. Therefore, the allegation "Staff handled resident roughly" is Substantiated at this time.

It was reported that "Staff did not notify authorized representative of an unusual incident with resident” and “Staff falsified documents” as it was alleged that R1 sustained a fall and that R1’s family/responsible party was not notified in a timely manner, although staff documentation indicated that notification had occurred. Interviews conducted and records reviewed revealed that R1 sustained a fall on 04/24/2026. Narrative charting notes dated 04/24/2026 through 04/25/2026 indicated that S2 documented that R1’s family/responsible party had been notified of the fall. However, interviews with R1’s family and the Generations Care Director, along with a review of records, revealed that S2 had been instructed to communicate to R1’s family the specific details of the incident.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/01/2026 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20260501144101

FACILITY NAME:PALMS AT BONAVENTURE, THEFACILITY NUMBER:
565850615
ADMINISTRATOR:MCCAULEY,BRANDYFACILITY TYPE:
740
ADDRESS:111 NORTH WELLS ROADTELEPHONE:
(805) 647-0616
CITY:VENTURASTATE:CAZIP CODE:
93004
CAPACITY:121CENSUS: 103DATE:
09/15/2026
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Brandy McCauleyTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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9
Staff did not reassess resident as necessary
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced subsequent complaint visit to deliver final findings of the allegations listed above. Upon arrival LPA met with Executive Director Brandy McCauley and explained the reason for the visit.

On 05/06/2026, LPA conducted an initial 10-day complaint visit to investigate the allegations listed above. At approximately 10:00 a.m. LPA conducted physical plant tour, interviewed staff and residents, obtained and reviewed Safely U Footage as well as obtained copies of pertinent documentation relevant to the investigation. On 08/21/2026, LPA conducted a subsequent complaint visit to continue investigation on the allegations listed above. At approx. 10:05 a.m. LPA conducted physical plant tour, interviewed staff, residents, families / responsible parties, as well as reviewed and obtained additional copies of pertinent documentation relevant to the investigation. On 09/01/2026, LPA reviewed additional records obtained from the facility.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 29-AS-20260501144101
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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, THE
FACILITY NUMBER: 565850615
VISIT DATE: 09/15/2026
NARRATIVE
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Continued from 9099-A

It was reported that “Staff did not reassess resident as necessary” as it was alleged that R1 sustained falls on 04/23/2026, 04/24/2026, and 05/02/2026 and was not evaluated in a timely manner. Interviews and record review showed that on 04/23/2026, R1 had an unwitnessed fall while attempting to walk to the bathroom. On 04/24/2026, R1 fell while S1 was forcibly attempting to change R1. On 05/02/2026, R1 was observed sitting on the floor in a common-area hallway. Records review of incident reports reflected that following each fall, R1's vital signs were obtained and R1 was assessed for the need for hospital evaluation. The facility also documented notifications of the physician by fax, family by telephone, and management. In addition, review of Physician communication records reflected that on 04/23/2026, the physician instructed the facility to continue the current plan of care. On 04/24/2026, the record indicated that there was no response from the physician. On 05/02/2026, the physician again instructed the facility to continue the current plan of care. Fall-risk evaluations were completed by the Generations Director on 04/26/2026 and 05/03/2026. Furthermore, on 05/12/2026, the Executive Director, Generations Director, R1's family, and the Ventura County Ombudsman met to review R1's service plan. The meeting addressed R1's recent falls, ongoing care needs, interventions, and care recommendations. The service plan was subsequently updated based on the recommendations discussed. R1 was admitted to hospice services on 05/14/2026. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff did not reassess resident as necessary” is deemed Unsubstantiated at this time.

Exit interview conducted and copy of report issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2026
LIC9099 (FAS) - (06/04)
Page: 7 of 7
Control Number 29-AS-20260501144101
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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, THE
FACILITY NUMBER: 565850615
VISIT DATE: 09/15/2026
NARRATIVE
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Continued from 9099-C

According to the Generations Care Director, S2 confirmed understanding of the instruction and documented in the incident report, as well as verbally stated, that S2 had contacted R1’s family. On 04/29/2026, R1’s family met with the Generations Care Director to review footage of a fall that the family had previously been informed had occurred on 04/23/2026. During the meeting, the Generations Care Director asked whether the family had also been notified of the subsequent fall that occurred on 04/24/2026. The family member stated that they had no knowledge of the 04/24/2026 fall and confirmed that the communication they had received was regarding the 04/23/2026 fall. LPA’s interview with ten (10) staff members, including the Generations Care Director and Executive Director. Interviews indicated that staff understood that, when an incident occurred, the Med Tech was responsible for notifying the resident’s family/responsible party, primary care physician, hospice, home health, and management, as applicable. Staff also understood that notifications were to be documented and supported by confirmation of receipt through fax, email, text message, telephone call, or other applicable means. Based on the information obtained during the investigation, the Department has sufficient evidence to confirm this allegation occurred. Therefore, the allegation " Staff did not notify authorized representative of an unusual incident with resident” and “Staff falsified documents” is Substantiated at this time.

Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 9099-D.) Executive Director was informed that failure to correct may result in civil penalties.

Exit interview conducted, and a copy of this report and appeal rights were provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 29-AS-20260501144101
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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, THE
FACILITY NUMBER: 565850615
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/16/2026
Section Cited
CCR
87468(a)(1)
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(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1)To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidence by:
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S1 has since been terminated and inservices were conducted. In Addition, licensee rep agreed to review section cited and provide a letter of understanding along with a written plan to ensure future compliance then send to LPA by COB 09/16/2026.
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Based on interviews and records review the licensee did not comply with the above cited section as S1 did not follow facility protocol and procedures when providing services to R1, which posed an immediate risk to resident in care
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 29-AS-20260501144101
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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, THE
FACILITY NUMBER: 565850615
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/02/2026
Section Cited
CCR
87211(a)(1)(D)
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Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met as evidenced by:
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Licensee rep agreed to review section cited and provide a statement of understanding along with a written plan to ensure future compliance then send to LPA via email by COB 10/02/2026.
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Based on interviews and records review, the licensee did not comply with the above-cited section by not timely notifying R1’s family of R1’s fall, which posed a potential health, safety or personal rights risk to residents in care.
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Type B
10/02/2026
Section Cited
CCR
87207
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False Claims No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement was not met as evidence by:
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Licensee rep agreed to review section cited and provide a statement of understanding along with a written plan to ensure future compliance then send to LPA via email by COB 10/02/2026
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Based on interviews and records review, staff documented and reported to their supervisor that R1’s family was notified of fall, however, the family was not notified, resulting in inaccurate documentation, which posed a potential health, safety or personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 7