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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 421703549
Report Date: 10/15/2020
Date Signed: 10/15/2020 01:45:41 PM



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
07/08/2020 and conducted by Evaluator Lyndia Sager
COMPLAINT CONTROL NUMBER: 29-AS-20200708121343
FACILITY NAME:DEVEREUX FOUNDATION - WEISMAN CENTER (RCFE)FACILITY NUMBER:
421703549
ADMINISTRATOR:CLAUDETTE CATIBAYANFACILITY TYPE:
740
ADDRESS:6960 DEVEREUX WAYTELEPHONE:
(805) 968-2525
CITY:GOLETASTATE: CAZIP CODE:
93117
CAPACITY:15CENSUS: 15DATE:
10/15/2020
ANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Mory Alvarez, Quality Assurance ManagerTIME COMPLETED:
01:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is hazardous
Medication records are inaccurate
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Lyndia Sager conducted a subsequent complaint investigation to deliver final investigation findings telephonically with Mory Alvarez, Quality Assurance Manager (QAM), Jennifer Farley, Assistant Program Director, and Roxanne Dryden, RN, due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures.

Allegation #1: Facility is hazardous. Photos provided show furniture was in the hallway obstructing part of the walkway. QAM stated that from Tuesday 07/07/20 approximately 9:00 a.m. to Wednesday 07/08/20 after lunch, the furniture was placed in the hallway from several resident’s bedrooms where facility maintenance was working on flooring. The next day the walkways were clear. During the 07/16/20 initial 10 day visit, LPA Sager observed the walkways to be free of obstruction. QAM stated the plan for furniture storage in the future is to store items in one of the outside sheds. Based on the information obtained during the course of the investigation, this allegation is deemed substantiated.
Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Lyndia SagerTELEPHONE: (805) 680-7683
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2020
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 3
Control Number 29-AS-20200708121343
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: DEVEREUX FOUNDATION - WEISMAN CENTER (RCFE)
FACILITY NUMBER: 421703549
VISIT DATE: 10/15/2020
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
26
27
28
29
30
31
32
Allegation #2: Medication records are inaccurate. Information obtained through interviews and review of the Medication Assistance Records (MARS) finds that the records were not accurate. Resident #1 (R1) PRN medication was listed on the MAR, but the medication was not available to give to R1 on 07/01/20. QAM submitted a new medication protocol dated 07/17/20 sent to the Program Leadership Teams addressing the areas of medication refills, medication destruction, discontinued medications and a back-up plan for PRNs if unable to contact a nurse. Proof that R1’s PRN medication refill was delivered on 07/17/20 was also submitted to Community Care Licensing. Based on the information obtained during the course of the investigation, this allegation is deemed substantiated.

Licensee was cited on 02/03/20 for a medication error. This is the second citation within a 12-month period, therefore, a civil penalty will be assessed.

Deficiencies issued on 9099-D, civil penalty assessed, Appeal Rights emailed.

A telephonic exit interview was conducted and a copy of the reports were provided via email for signature.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Lyndia SagerTELEPHONE: (805) 680-7683
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20200708121343
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: DEVEREUX FOUNDATION - WEISMAN CENTER (RCFE)
FACILITY NUMBER: 421703549
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/15/2020
Section Cited
CCR
87465(c)(2)
1
2
3
4
5
6
7
87465 (c)(2) Incidental Medical and Dental Care
Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee submitted a new medication protocol dated 07/17/20 sent to the Program Leadership Teams addressing the areas of medication refills, medication destruction, discontinued medications and a back up plan if unable to contact a nurse. Proof that (R1) PRN medication refill was delivered on 07/17/20 was also submitted to Community Care Licensing. Plan of Correction complete
8
9
10
11
12
13
14
Based on record review, the licensee failed to ensure medications were given as prescribed, which posed an immediate health and safety risk to clients in care.
8
9
10
11
12
13
14
Type B
10/15/2020
Section Cited
CCR
87307(d)(6)
1
2
3
4
5
6
7
87307 Personal Accommodations and Services
(d) The following space and safety provisions shall apply to all facilities:
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee removed the furniture from the hallway and has a plan in place for the furniture storage in the future will be stored in outside sheds and not in the walkways. Plan of correction complete
8
9
10
11
12
13
14
Based on interviews conducted and photos of the walkway, Licensee failed to follow the above regulation which poses a potential health, safety, and personal rights risk to residents in care.
8
9
10
11
12
13
14
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: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Lyndia SagerTELEPHONE: (805) 680-7683
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 3