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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425801744
Report Date: 03/18/2022
Date Signed: 03/18/2022 01:15:07 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
08/28/2020 and conducted by Evaluator Kristin Kontilis
COMPLAINT CONTROL NUMBER: 29-AS-20200828144317
FACILITY NAME:DEVEREUX CALIFORNIA - CASA FELIZFACILITY NUMBER:
425801744
ADMINISTRATOR:FARLEY, JENNIFERFACILITY TYPE:
735
ADDRESS:6990 FALBERG WAYTELEPHONE:
(805) 968-2525
CITY:GOLETASTATE: CAZIP CODE:
93117
CAPACITY:7CENSUS: 5DATE:
03/18/2022
UNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Joel Goforth, Program AdministratorTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Facility did not follow reporting requirements.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced subsequent complaint visit to issue final findings. During the investigation, LPA reviewed various documents including but not limited to incident reports and communication logs. On 9/3/2020 between 1:30 pm and 3:30 pm, LPA interviewed staff about the allegations and interviewed Client 1's (C1’s) responsible party on 9/2/2020.
Entrance interview conducted:
On 3/16/2020, CCL received an incident report stating an incident occurred on 3/10/2020 between Client 1 (C1) and Client 2 (C2). C2 was aggressive to C1 and kicked C1. The incident was reported to facility staff and to CCL; however, the incident report does not indicate it was reported to C1’s or C2’s responsible parties. C1’s responsible party stated they were not notified of this incident.
On 5/13/2020, CCL received an incident report stating an incident occurred on 5/9/2020 between C1 and C2. C2 was aggressive to C1 and hit C1. The incident was reported to facility staff and to CCL; however, the incident report does not indicate it was reported to C1’s or C2’s responsible parties. C1’s responsible party stated they were not notified of this incident. Please continue to 9099-C, Pg 2.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022
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-20200828144317
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: 03/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/22/2022
Section Cited
CCR
80061(f)
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80061(f) Reporting Requirements: The items specified in (b)(1)(A) through (H) above shall also be reported to the client's authorized representative, if any.

This requirement was not met as evidenced by:
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Administrator agrees to provide a written plan in place including but not limited to reporting procedures to all required parties including a description of a consistent procedure to comply with the regulation. Administrator agrees to conduct training to all staff on procedures for reporting incidents to all required parties.
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Based on record review and interviews conducted, the licensee did not ensure C1’s responsible party was notified of unusual incidents involving C1 that occurred on 3/10/2020, 5/9/2020, and 5/22/2020, which posed a potential health and safety risk to clients 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.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20200828144317
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: 03/18/2022
NARRATIVE
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 On 5/22/2020, CCL received an incident report stating an incident occurred on 5/17/2020 between C1 and C2. C2 swung their arms at C1 and hit C1. The incident was reported to facility staff and to CCL. Although the incident report indicates C2’s responsible party was notified of the incident, it does not state C1’s responsible party was notified. C1’s responsible party stated they were not notified of this incident.

Exit interview conducted. Deficiency cited on 9099-D. Report issued via email. Appeal rights issued via email.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3