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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801744
Report Date: 12/06/2022
Date Signed: 12/06/2022 02:00:37 PM

Document Has Been Signed on 12/06/2022 02:00 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 - CASA FELIZFACILITY NUMBER:
425801744
ADMINISTRATOR:JOEL GOFORTHFACILITY TYPE:
735
ADDRESS:6990 FALBERG WAYTELEPHONE:
(805) 968-2525
CITY:GOLETASTATE: CAZIP CODE:
93117
CAPACITY: 7CENSUS: 7DATE:
12/06/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Antonela Milito, Program ManagerTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced Case Management – Incident visit to the facility today. LPA met with Jennifer Farley, Program Director and Antonela Milito, Program Manager.
The purpose of today’s visit is to address two self-reported incidents reported to CCL on 11/28/2022 and 11/29/2022.
Incident #1: Program Administrator reported Client 1 (C1) is prescribed one (1) dose of two (2) tablets of Escitalopram 20 mg at 8:00 am each morning. On 11/26/2022, Staff discovered one tablet of Escitalopram 10 mg remained in the bubble pack. It was determined that C1 was not given the full 20 mg dosage and was only administered one (1) tablet of the Escitalopram on 11/21/2022 at approximately 8:00 am.
Incident report states Staff 1 (S1) and Staff 2 (S2) will be provided medication re-training and second medication check procedure has been changed to be conducted before medications are administered rather than after the medications are administered.
Incident #2: Client 2 (C2) is prescribed a daily dosage at 12:00 pm of Chlorpromazine 50 mg; Hydroxyzine PAM 25 mg; Quetiapine Fumarate 200 mg; and Clonazepam 0.5 mg. On 11/28/2022, Antonella Milito, Program Manager became distracted and did not administer C2’s 12:00 pm prescribed medications. Incident report states Program Manager will be provided medication re-training.
During today’s visit, LPA obtained copies of “Client at a Glance” (Client’s face sheet including contact information), Doctor’s orders for medications, and Medication Accounting Record (MAR) for C1 and C2. LPA toured the facility with Program Manager and reviewed medications for C1 and C2.
LPA conducted an interview with Program Administrator on 12/6/2022 starting at 1:38 pm. Based on record review and interview(s) conducted, it was determined that the licensee did not ensure C1 and C2 were assisted with their medication(s) as prescribed.

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 via email.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2022
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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Document Has Been Signed on 12/06/2022 02:00 PM - It Cannot Be Edited


Created By: Kristin Kontilis On 12/06/2022 at 01:51 PM
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 - CASA FELIZ
FACILITY NUMBER: 425801744

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/07/2022
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 Manager agrees to conduct scheduled medication training from an outside medical vendor for all staff. Program Manager agrees to provide documentation and description of scheduled medication to LPA via email no later than 12/7/2022.
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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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CIVIL PENALTY ASSESSED - Repeat violation

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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: 12/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2022


LIC809 (FAS) - (06/04)
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