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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 421703549
Report Date: 04/28/2023
Date Signed: 05/01/2023 04:03:30 PM

Unsubstantiated


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
01/24/2023 and conducted by Evaluator Kristin Kontilis
COMPLAINT CONTROL NUMBER: 29-AS-20230124170445
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
UNANNOUNCEDTIME BEGAN:
01:21 PM
MET WITH:Jennifer Farley, Program DirectorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Due to staff neglect, resident sustained fractures while in care.
Due to staff neglect, resident developed a UTI while in care resulting in sepsis.
Facility staff failed to seek medical attention for resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kristin Kontilis conducted a subsequent complaint visit to deliver findings for the above allegations. LPA met with Jennifer Farley, Program Director; Enedelia Avila, Staff in Charge; and Antonela Milito, Program Manager and explained the reason for the visit.
On 01/24/2023, the Department received a complaint regarding allegations of Neglect/Lack of Supervision. It was alleged that Resident #1 (R1) sustained fractures while in care; developed a urinary tract infection (UTI) while in care resulting in sepsis; and the facility staff failed to seek medical attention for R1. The complaint was referred to the Community Care Licensing Investigations Branch (IB) and assigned to Investigator Peter Zertuche.
On 01/25/2023, from 1:30 pm to 3:30 pm, Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced initial 10-day complaint investigation based on the allegations stated above. LPA Kontilis met with Omar Garcia, Program Manager and Enedelia Avila, Program Administrator. Jennifer Farley, Program
Please continue to 9099-C, Pg 2.


Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 29-AS-20230124170445
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: 04/28/2023
NARRATIVE
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Director. LPA arrived at approximately 1:55 pm. LPA explained the purpose of the visit. LPA conducted a physical tour of the facility to ensure health and safety precautions were met. During the visit, LPA obtained various documents pertinent to the investigation. From 2:35 pm to 3:00 pm, LPA conducted a brief interview with Program Administrator and Program Director. LPA noted further investigation was required and advised that the complaint would be investigated by the Community Care Licensing Investigations Branch (IB).
On 2/10/2023 from approximately 12:00 pm to 2:30 pm, Investigator Zertuche conducted interviews with Facility Administrator, facility nurse, residents, staff, Santa Barbara Coroner’s Office, and representative of the Chumash Casino Security Department. On 02/15/2023 from approximately 1:00 pm to 2:30 pm, Investigator Zertuche conducted interviews with R1’s resident representative, Tri-Counties Regional Center Service Coordinator, and a representative of the Chumash Casino Risk Management Department. Investigator Zertuche conducted interviews on 03/30/2023 from approximately 3:15 pm to 3:30 pm with Tri-Counties Regional Center Quality Assurance Specialist and Santa Barbara County Coroner’s Office; on 04/06/2023, at approximately 12:00 pm, with R1’s Urology Specialist of Urology Specialists of Santa Barbara. Additionally, Investigator Zertuche reviewed medical records, Chumash Casino 12/16/2022 video footage, and facility file documents, including Unusual Incident Reports (UIRs), related to R1.
A review of R1’s facility admission documentation and physician report listed R1’s diagnoses as Major Depressive Disorder, Autism Spectrum Disorder, with a history of Diabetes Type II and Bladder Disorder. Information obtained from documents and interviews with R1’s responsible party, Tri-Counties Regional Center Service Coordinator and Quality Assurance Specialist, and facility staff confirmed that R1 was independent and able to go on outings on their own. R1 visited the Urology Specialists of Santa Barbara monthly to exchange R1’s suprapubic catheter. R1’s last visit was 12/08/2022 for a routine tube change. During the visit, there was some inflammation found on the tube and R1 was provided antibiotics. Dr. Chacko, Urology Specialist, indicated it was not a urinary tract infection (UTI).
A review of the Chumash Casino video footage revealed that on 12/16/2022, at 4:02 pm, R1 was standing with a group of guests waiting for the bus to arrive. R1’s legs started to bend and R1 gradually fell to the ground. The Chumash Casino Emergency Medical Technician (EMT) conducted a physical assessment of R1. R1 stated they felt dizzy and fell. R1 denied any head, neck, or back pain. R1 stated they had hurt their right shoulder earlier in the day and it was still hurting. R1 stated “I’m ok, need to catch the bus” and refused medical treatment. The EMT then assisted R1 onto the bus.
Please continue to 9099-C, Pg 3.,
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
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
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 29-AS-20230124170445
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: 04/28/2023
NARRATIVE
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 According to an Unusual Incident Report submitted by the facility, R1 visited the Chumash Casino on 12/16/2022. R1 went independently using the bus from downtown Santa Barbara. R1 was transported to the bus stop in the morning by facility staff members. As R1 was walking toward the bus, R1 fell on a grassy area but seemed okay and did not report any pain. R1 continued the outing. In the evening, staff members picked up R1 from the same bus stop, R1 reported they fell while at the casino and complained of pain to the arm. R1 was seen by a paramedic who was at the facility for another resident and advised R1 should be taken to the hospital for x-rays. R1 was then transported by staff members to the hospital and was admitted for a fractured arm. On 12/18/2022, the facility received an update from the hospital that R1 sustained a dislocated shoulder and was advised they would be discharged later that day or the next. On 12/19/2022, the facility was informed by the hospital that R1 sustained fractured ribs and would require rehabilitation prior to returning to the facility. The facility contacted R1’s resident representative to discuss skilled nursing facility options. On 12/21/2022, R1’s resident representative contacted the facility to report that R1 passed away the night before. R1’s resident representative reported R1 had a broken arm, dislocated shoulder, UTI, broken ribs, pneumonia, and had become septic.
A review of the Goleta Valley Cottage Hospital medical records revealed R1 was admitted to the hospital on 12/16/2022 due to concerns about a shoulder injury due to a fall. According to the doctor, it appeared that a urinary tract infection precipitated R1’s symptoms, and the fall was likely due to generalized weakness from sepsis. R1 sustained a humeral fracture to the shoulder. A CT scan of the head revealed no hemorrhages or fractures. R1 also had multiple rib fractures on the right side and developed pneumonia. Hematoma and swelling were also noted on R1’s right eyebrow; however, this was not observed by facility staff or medical personnel at Chumash Casino earlier in the day. Lab notes dated 12/16/2022 showed R1 was a low risk for septic shock, but other notes indicated R1 had urinary sepsis upon admission which was most likely attributed to R1’s falls. On 12/19/2022, R1 vomited; R1 aspirated and had worsening pneumonia the following morning and became unresponsive. R1’s status was changed to comfort care, and R1 passed away shortly after midnight on 12/21/2022.
R1’s Urology specialist was aware R1 was diagnosed with a UTI and sepsis during their hospital visit after R1’s fall. The specialist argued against it stating there is often a positive reading in these cases and there was no evidence of UTI/sepsis, and it is possible but unlikely. The doctor stated many doctors use this diagnosis without properly going through the testing process and the urine always carries germs which could show a positive reading, but it is not proven unless further tests are conducted. The doctor did not believe the fall was the cause of death as R1 had many medical issues and aspirated while in the hospital which led to an infection and ultimately R1’s death. Please continue to 9099-C, Pg 4
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
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
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 29-AS-20230124170445
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: 04/28/2023
NARRATIVE
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On the allegation “Due to staff neglect, resident sustained fractures while in care.” All witnesses, including R1’s resident representative, reported nothing unusual prior to R1’s 12/16/2022 fall. R1 reportedly fell prior to going to the Chumash Casino but stated they were okay. R1 fell again when leaving the casino later in the afternoon and indicated to the casino’s medical personnel that that they were okay. R1 was taken to the hospital when they returned to the facility where they were diagnosed with fractures to the shoulder and ribs. The Department did not find sufficient evidence to support the allegation, therefore the allegation “Due to staff neglect, resident sustained fractures while in care” is deemed Unsubstantiated at this time.
On the allegation “Due to staff neglect, resident developed a UTI while in care resulting in sepsis.” All witnesses, including R1’s resident representative, reported nothing unusual prior to R1’s 12/16/2022 fall. R1 was taken to the hospital when they returned to the facility and was diagnosed with a UTI and sepsis as well as fractures to the shoulder and ribs. R1’s Urology Specialist, MD, did not believe there was neglect in this case as R1 visited the doctor monthly to change their catheter with the last visit on 12/08/2022, approximately one week prior to the incident. R1’s doctor indicated it would be difficult for a person to know if someone had a UTI since it is internal unless the symptoms are severe, such as fever and confusion, which was not reported by anyone. The Department did not find sufficient evidence to support the allegation, therefore the allegation “Due to staff neglect, resident developed a UTI while in care resulting in sepsis” is deemed Unsubstantiated at this time.
On the allegation “Facility staff failed to seek medical attention for resident.” All witnesses, including R1’s resident representative, reported nothing unusual prior to R1’s 12/16/2022 fall. R1 reportedly fell prior to going to the casino but stated they were okay and wanted to continue on the trip to the casino. R1 fell again when leaving the casino later in the afternoon and indicated they were okay to the casino’s medical personnel. R1 was taken to the hospital when they returned to the facility where R1 was diagnosed with fractures to the shoulder and ribs. The Department did not find sufficient evidence to support the allegation, therefore the allegation “Facility staff failed to seek medical attention for resident” is deemed Unsubstantiated at this time.

Exit interview conducted. No deficiencies cited. Copy of report issued at the time of the visit.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
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
LIC9099 (FAS) - (06/04)
Page: 4 of 4