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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801326
Report Date: 04/11/2022
Date Signed: 04/11/2022 04:54:47 PM

Document Has Been Signed on 04/11/2022 04:54 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 CALIFORNIA - ADULT DAY CAREFACILITY NUMBER:
425801326
ADMINISTRATOR:WEST, AMYFACILITY TYPE:
775
ADDRESS:6960B FALBERG WAYTELEPHONE:
(805) 968-2525
CITY:GOLETASTATE: CAZIP CODE:
93117
CAPACITY: 60CENSUS: 0DATE:
04/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Nellie JustTIME COMPLETED:
05:05 PM
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Licensing Program Analyst (LPA) Toan Luong conducted an unannounced on-site One Year Infectious Control Annual visit to the facility. LPA met with Administrator Nellie Just and explained the purpose of the visit.

Administrator took LPA on a physical plant tour of the facility. The facility has submitted a mitigation plan to the department. The facility is not currently open to clients.

At 4:15 p.m., LPA discussed items in the Infection Control Module with administrator and noted that the facility did not have signs to report acute respiratory illness to staff nor cough/sneeze etiquette signage. Other Covid-19 signs were posted throughout the facility such as social distancing and wearing masks. All other items in the Infection Control Module were answered yes.

LPA reviewed the Infection Control Tool Module with administrator to satisfaction.

Exit interview was conducted. No deficiencies cited and report emailed to administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2022
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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