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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 421703549
Report Date: 01/25/2023
Date Signed: 01/25/2023 07:23:06 PM

Document Has Been Signed on 01/25/2023 07:23 PM - 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: 14DATE:
01/25/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Enedelia Avila, Program AdministratorTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kristin Kontilis conducted a Case Management visit to address deficiencies noted during Complaint Control #29-AS-20230124170445 investigation visit conducted on 1/25/2023. LPA met with Omar Garcia, Program Manager/Administrator and Enedelia Avila, Program Administrator/Direct Support Professional (DSP)/Certified Nursing Assistant (CNA). Jennifer Farley, Program Director arrived at approximately 1:55 pm. LPA explained the purpose of the visit.

Entrance interview conducted:
LPA conducted a physical tour of the facility. At approximately 1:35 pm, LPA entered the hallway near the kitchen service area of the facility and observed Staff 1 (S1), Staff 2 (S2), and Staff 3 (S3) were not properly wearing face coverings. The face coverings of S1, S2, and S3 were worn under the chin of each person’s face and not covering their nose or mouth. S1, S2, and S3 were not eating or consuming a beverage. At the time of LPA's observation. LPA requested each staff member to properly cover their face with a proper face covering. LPA reminded staff members that a face covering is to be worn in the facility at all times.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D):

Exit interview conducted. Copy of report and Appeal Rights issued via email.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE: DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/25/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/25/2023 07:23 PM - It Cannot Be Edited


Created By: Kristin Kontilis On 01/25/2023 at 02:05 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: 01/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/26/2023
Section Cited
CCR
87468.1(a)(2)

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87468.1(a)(2) Personal Rights of Residents in All Facilities: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
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Administrator agrees to notify all staff to wear masks at all times in the facility. Administrator agrees to conduct an infectious control training, review and train staff on all recent PIN’s released for 2022 and 2023, including mask-wearing mandates, and provide copy of training and staff signatures to CCL by 1/26/2023.
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Based on LPA observation, Licensee failed to ensure all staff wore face coverings properly at all times while in the facilities. Staff 1, Staff 2, and Staff, 3 were not properly wearing a mask at the time LPA entered into the facility which poses an immediate health, safety and personal rights risk to residents in care.
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List of attendees with signatures to include first and last name of each attendee shall be provided to LPA via email.

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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:Kelly Burley
LICENSING EVALUATOR NAME:Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2023


LIC809 (FAS) - (06/04)
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