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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 421703549
Report Date: 06/14/2023
Date Signed: 06/14/2023 05:19:22 PM

Document Has Been Signed on 06/14/2023 05:19 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: 15DATE:
06/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:39 AM
MET WITH:Omar Garcia, Program ManagerTIME COMPLETED:
05:45 PM
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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced Annual required inspection at the facility. LPA arrived at 11:39 am and was greeted by Omar Garcia, Program Manager and Monica Gomez, Clinical Case Manager. Jennifer Farley, Program Director was unavailable at the time of the visit. LPA explained the purpose of the visit. There are currently fifteen (15) clients residing in the facility. At the time of arrival, there were fourteen (14) clients present, one client is away from the facility, and five (5) staff were on duty. LPA informed staff of the visit.

Entrance interview conducted.
The facility is a one-story home to Clients with intellectual/developmental disabilities, has a fire clearance for 15 non-ambulatory clients and a hospice waiver for 2 clients. The facility contracts with Tri-Counties Regional Center.
A tour of the physical environment and accommodations were assessed, and the following was noted: LPA observed the required posting of the complaint poster, bill of rights and Resident’s Rights. LPA inspected the one-story facility for fire safety, personal accommodations, and food service.
The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, doors, floors and floor coverings were checked. The facility was seen to be in good repair inside and outside. LPA observed four (4) fire extinguishers serviced on 4/12/2023, two (2) carbon monoxide detectors in good working order, 27 smoke alarms, and an automatic sprinkler system throughout the building.
The kitchen area was sufficiently stocked with two-day perishables and seven days of non-perishables. Frozen foods are properly wrapped and stored appropriately. LPA observed the kitchen cabinets, refrigerator, stove, and counters are clean.
A weekly meeting is conducted with Staff in Charge (SIC) to discuss clients’ activities and planning for activities for the upcoming week. Clients participate at will in activities with painting projects, Bingo, and
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SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2023
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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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
VISIT DATE: 06/14/2023
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greenhouse planting. Clients also participate independently in arts and crafts, excursions to the local eateries, entertainment places, walks, and places of worship.
Medications and First Aid kits are kept in the locked staff office in a locked medication cart.
Meals are prepared by the facility cook. Staff assists with meal distribution and assisting clients with safety precautions and special diet accommodations. Snacks are available throughout the day. Clients may volunteer to complete chores throughout the facility if desired.
The front entrance consists of an open porch with a bench located near the front door. The facility maintains a comfortable temperature and there are no bodies of water.
The facility has twelve (12) bedrooms. Bedrooms #1, 5, and 9 are shared bedrooms. Bedroom #9 has a private bathroom for the two occupants. Bedrooms #11 and 12 are single rooms with a shared bathroom between the two rooms. Bedrooms #2, 3, 4, 6, 7, 8 and 10 are private bedrooms. There are 5 bathrooms with access from the hallway available to all clients and staff. The bathrooms have secure grab bars.
All staff have been properly associated to the facility.
Personnel records and staff records are complete.

Exit interview conducted. No citations issued. A copy of this report issued at the time of the visit.l.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023
LIC809 (FAS) - (06/04)
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