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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 421703549
Report Date: 04/28/2023
Date Signed: 10/10/2023 09:32:54 AM


Document Has Been Signed on 10/10/2023 09:32 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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
ADMINISTRATOR:ENEDILIA AVILAFACILITY TYPE:
740
ADDRESS:6960 DEVEREUX WAYTELEPHONE:
(805) 879-0338
CITY:GOLETASTATE: CAZIP CODE:
93117
CAPACITY:15CENSUS: 15DATE:
04/28/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:21 PM
MET WITH:Jennifer Farley, Program DirectorTIME COMPLETED:
03:30 PM
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
Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced Case Management – Incident visit to the facility. LPA met with Jennifer Farley, Program Director and Enedelia Avila, Staff in Charge (SIC).
The purpose of today’s visit is to address two self-reported incidents reported to CCL on 4/12/2023 and 4/25/2023.

Incident #1: CCL received an incident report stating on 4/10/2023 Staff 1 (S1) conducted a medication count and discovered one capsule of Cephalexin 500mg over the amount of Resident 1’s (R1’s) prescribed medications. Additionally, there was a missing initial for 4/7/2023 at 12 pm. The incident report states the missing initial belongs to Staff 2 (S2).

Incident #2: On 4/25/2023, CCL received an incident report stating Staff 3 (S3) forgot to administer Resident 2’s (R2’s) 12 pm medication of Cephalexin 500mg (1 capsule) on 4/23/2023. The incident report states S2 discovered the capsule inside R2’s medication bubble pack.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to 809-D).
Exit interview conducted. Copy of report and appeal rights issued at the time of the visit. Civil penalty issued.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023
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 2


Document Has Been Signed on 10/10/2023 09:32 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/01/2023
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.
1
2
3
4
5
6
7
Program Director agrees to schedule medication training for all staff by POC due date.
Program Director agrees to conduct medication training from an outside source for all staff. Proof of training will include first and last name of trainees, name of trainer
8
9
10
11
12
13
14
This requirement is not met as evidenced by:
Based on records review, the licensee did not comply with the section cited above when staff did not follow physician’s orders for medications, which posed an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
trainer, description of training. Training sign-in sheet to be provided to LPA via email.


CIVIL PENALTTY ASSESSED

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2