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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425801744
Report Date: 11/09/2021
Date Signed: 11/09/2021 03:08:16 PM

Substantiated


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
05/25/2021 and conducted by Evaluator Toan Luong
COMPLAINT CONTROL NUMBER: 29-AS-20210525122713
FACILITY NAME:DEVEREUX CALIFORNIA - CASA FELIZFACILITY NUMBER:
425801744
ADMINISTRATOR:KAREN DACOMEFACILITY TYPE:
735
ADDRESS:6990 FALBERG WAYTELEPHONE:
(805) 968-2525
CITY:GOLETASTATE: CAZIP CODE:
93117
CAPACITY:7CENSUS: 4DATE:
11/09/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Leticia Villarreal, Quality Management ManagerTIME COMPLETED:
12:55 PM
ALLEGATION(S):
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Staff did not give resident a dose of medication.
INVESTIGATION FINDINGS:
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LPA reviewed a special incident report the facility submitted on 5/5/21. The incident report states on 5/1/2021 at apporximately 12:47 PM, Staff (S1) noticed S1 provided Client 1 (C1) the 5 PM bubble pack of medication instead of the 12 PM bubble pack of medication. As a result, C1 took C1's 5 PM medication at 12 PM. S1 contacted their supervisor about the medication error. C1's physician was also contacted and advised to give the 5 PM medications at 5 PM. S1 recieved additional medication training.
On 11/9/21 at 9:50 AM, Licensing Program Analyst (LPA) Toan Luong conducted a facility risk assessment with Quality Management Manger (QMM) Leticia Villarreal. At 11:00 AM, Licensing Program Manger (LPM) Kelly Burley and LPA Luong conducted complaint inspection at Devereux - Casa Feliz to deliver final findings. Today’s investigation was conducted on-site with Quality Management Manager (QMM) Leticia Villarreal.
On 11/9/2021 at 11:00am, LPA and LPM conducted a medication audit for all 4 clients for November 1 to November 9, 2021 and observed that all medications were given as prescribed. Administrator explained the facility implemented a new medication procedure and have had a decrease in medication errors.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
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 3
Control Number 29-AS-20210525122713
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 CALIFORNIA - CASA FELIZ
FACILITY NUMBER: 425801744
VISIT DATE: 11/09/2021
NARRATIVE
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Based on the information obtained, the allegation “Staff did not give resident a dose of medication” is substantiated at this time.
Exit interview, deficiency cited, report issued, appeal rights given.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20210525122713
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 CALIFORNIA - CASA FELIZ
FACILITY NUMBER: 425801744
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/09/2021
Section Cited
CCR
80075(b)
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80075 Health Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement was not met as evidenced by: Client did not receive correct medication as prescribed which posed an immediate health and safety risk.
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Facility has switched to a new pharmacy and has implemented a new procedure for passing out medication.
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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.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3