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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801326
Report Date: 03/10/2023
Date Signed: 03/10/2023 11:40:30 AM

Document Has Been Signed on 03/10/2023 11:40 AM - 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: 35DATE:
03/10/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:58 AM
MET WITH:Nellie Just, Program AdministratorTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced Case Management – Incident visit to the facility. LPA met with Jennifer Farley, Program Director and Nellie Just, Program Administrator.

CCL received an incident report stating on 12/28/2022, Client 1 (C1) was not administered their 2 pm dosage of Risperidone 2mg. Medications were packed by Staff 1 (S1) for C1 who was leaving the facility for an outing. Per the incident report, the fire alarm sounded unexpectedly and S1 began assisting clients with evacuating the building. When S1 returned to the building, S1 began assisting clients with hygiene and helping them gather their belongings to end their day at the day program.


The error was discovered on 12/30/2022 by Staff 2 (S2) when preparing C1's medication.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to 809-D).
Exit interview conducted. Copy of report and appeal rights issued during the visit.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2023
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 03/10/2023 11:40 AM - It Cannot Be Edited


Created By: Kristin Kontilis On 03/10/2023 at 11:23 AM
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 CALIFORNIA - ADULT DAY CARE
FACILITY NUMBER: 425801326

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/13/2023
Section Cited
CCR
80075(b)(5)(B)

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80075(b)(5)(B) Health Related Services. Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
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Program Director agrees to conduct scheduled medication error review with S1 by facility's Learning Specialist. Program Director agrees to provide documentation and description of scheduled medication to LPA via email no later than 3/14/2023.
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Based on records review, the licensee did not comply with the section cited above when staff did not follow physician’s orders for medications, which posed an immediate health and safety risk to residents in care.
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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: 03/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2023


LIC809 (FAS) - (06/04)
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