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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801326
Report Date: 03/14/2024
Date Signed: 03/14/2024 02:46:41 PM

Document Has Been Signed on 03/14/2024 02:46 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:NELLIE JUSTFACILITY TYPE:
775
ADDRESS:6960B FALBERG WAYTELEPHONE:
(805) 968-2525
CITY:GOLETASTATE: CAZIP CODE:
93117
CAPACITY: 60CENSUS: 22DATE:
03/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Micaela McGee, Assistant SupervisorTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced annual required visit. LPA met and toured the facility with Micaela McGee, Assistant Supervisor, Direct Support Professional, James Abrokwah, Program Manager, and Michele LaGrange, Case Manager/Direct Care Professional.
The facility location is in a rural area of the community. The facility is located in a multi-use building. The facility hours are Monday through Friday, 9 am to 3:00 pm. The program site is clean, safe, sanitary, and in good repair.
The facility provides program activities on-campus and off-campus. The activities include outings to art classes, museums, parks, retail businesses, libraries, animal shelters, bowling, and local eateries. Additional activities include trips to areas outside the community, greenhouse planting and growing, creating ceramic pots for retail, baking, reading and writing skill building, karaoke, meditation, communication skill building, and board games. The facility participates in Positive Behavior Reinforcement Intervention and Support, which is a program that focuses on an individual’s sense of control and self-government by making decisions in a structured meeting format
The facility floor plan consists of two offices, four restrooms, two kitchens, two common areas, a computer room, a sensory room, a gym room, a storage area for personal belongings.
Sharps are kept in locked drawers in the kitchens with no access to participants. Participants bring their own lunches or return to their residence for their noontime meal. The facility provides a morning and afternoon snack for all the participants.
The First Aid kit was observed to be complete. LPA observed four fire extinguishers with last inspection conducted on 1/25/2024.
Centrally stored medications are inaccessible t and kept to participants and are kept n a locked box in a locked cabinet in the locked medication room.

Please continue to 809-C, Pg 2..

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2024
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 CALIFORNIA - ADULT DAY CARE
FACILITY NUMBER: 425801326
VISIT DATE: 03/14/2024
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 LPA reviewed Individuals’ records including but not limited to Identification Profile, Admission Agreements, health screenings, Needs and Services Plan, Pre-Appraisals, and Clients’ rights.
Personnel records were reviewed for criminal background clearance, health screenings, and trainings.
LPA recommended LIC610E (3/19) be updated and included in the Emergency Disaster binder.


Exit interview conducted. Technical Advisory noted. Copy of report issue at the time of the visit.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024
LIC809 (FAS) - (06/04)
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