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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801744
Report Date: 03/10/2023
Date Signed: 03/10/2023 12:24:54 PM

Document Has Been Signed on 03/10/2023 12:24 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:ANTONELA MILITOFACILITY TYPE:
735
ADDRESS:6990 FALBERG WAYTELEPHONE:
(805) 968-2525
CITY:GOLETASTATE: CAZIP CODE:
93117
CAPACITY: 7CENSUS: 7DATE:
03/10/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Antonela Milito, Program AdministratorTIME COMPLETED:
12:30 PM
NARRATIVE
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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 Antonela Milito, Program Administrator.
The purpose of today’s visit is to address two self-reported incidents reported to CCL on 12/12/2022 and 1/25/2023.

Incident #1: CCL received an incident report stating on 12/7/2022, Staff 1 (S1) discovered a partially dissolved pill of Clonazepam 0.5 mg under the facility couch. Incident report states S1 did not follow medication administration protocol and must not have stayed with Client for 5-10 minutes to ensure Client has swallowed the medication.

Incident #2: On 1/25/2023, CCL received an incident report stating Client 1 (C1) approached Staff 2 (S2) and Program Administrator Antonela Milito with two pills that looked old and chewed. The date the pills were to be consumed is unclear but presumed to have occurred on 1/23/2023 because Staff 3 (S3), on-call staff, did not follow the process correctly. In November 2022, medication procedure changed to include two staff watch clients take their meds. On 1/23/2023, S3 was observed not following the process during the evening med pass. Incident report states S3 was given immediate feedback however a supervisor was not there at bedtime to monitor the medication distribution.

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. Civil penalty issued.

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 12:24 PM - It Cannot Be Edited


Created By: Kristin Kontilis On 03/10/2023 at 12:10 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: 03/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/14/2023
Section Cited
CCR
80075(k)(1)

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80075(k)(1) Health Related Services: (k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
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Program Director agrees to conduct scheduled medication error review with S3 and S4 and medication protocol with all staff. 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 facility’s medication administration protocol, which posed an immediate health and safety risk to residents in care.
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Civil penalty assessed.

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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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