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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 421703549
Report Date: 05/27/2021
Date Signed: 05/28/2021 08:36:08 AM

Document Has Been Signed on 05/28/2021 08:36 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:LORETTA CALDERONFACILITY TYPE:
740
ADDRESS:6960 DEVEREUX WAYTELEPHONE:
(805) 968-2525
CITY:GOLETASTATE: CAZIP CODE:
93117
CAPACITY: 15CENSUS: 15DATE:
05/27/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jennifer FarleyTIME COMPLETED:
02:45 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 Visit to address an issue of Administrator change to the facility. LPA met with Jennifer Farley, Program Director and Clare Penny, Assistant Clinical Director. LPA stated the purpose of the visit.

Entrance interview conducted.

On 2/16/2021, CCL received notification and documentation via email of a new administrator assignment to the facility. From 2/25/2021 through this date, email exchanges took place including clarification and correction to name the new administrator to the facility. On 2/14/2021, Karen Dacome was named the new Administrator. Due to paperwork being incomplete, CCL was unable to complete the process of naming Dacome to the facility. Dacome’s term as facility Administrator ended on 5/12/2021.

Based on interview and record review, the Licensee did not ensure the facility had a certified administrator on the premises a sufficient number of hours to adequately administer the facility which poses an immediate health and safety risk to residents in care.

Exit interview conducted. Citation issued (see 809-D). Copy of report issued.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE: DATE: 05/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/27/2021
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 05/28/2021 08:36 AM - It Cannot Be Edited


Created By: Kristin Kontilis On 05/27/2021 at 01:53 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 05/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/28/2021
Section Cited
CCR
87405(a)

1
2
3
4
5
6
7
87405(a) Administrator – Qualifications and Duties: All facilities shall have a qualified and currently certified administrator....

This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Program Director agrees to submit to CCL the required paperwork in full no later than end of day, May 28, 2021.
8
9
10
11
12
13
14
Based on interview and record review, the administrator failed to ensure the facility had a certified administrator on the premises when the facility failed to submit the required paperwork within 30 days of the new administrator designation which poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14

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 Burley
LICENSING EVALUATOR NAME:Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:
DATE: 05/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2021


LIC809 (FAS) - (06/04)
Page: 2 of 2