425801744-4-8-2022-29-AS-KBUY-CDDUZ6-20220411160102

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425801744
Report Date: 04/08/2022
Date Signed: 04/08/2022 04:25:06 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
07/06/2021 and conducted by Evaluator Toan Luong

COMPLAINT CONTROL NUMBER: 29-AS-20210706115410

FACILITY NAME:	DEVEREUX CALIFORNIA - CASA FELIZ		FACILITY NUMBER:	425801744
ADMINISTRATOR:	MEGHAN STALLWORTH		FACILITY TYPE:	735
ADDRESS:	6990 FALBERG WAY		TELEPHONE:	(805) 968-2525
CITY:	GOLETA	STATE: CA	ZIP CODE:	93117
CAPACITY:	7	CENSUS: 7	DATE:	04/08/2022
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Jennifer Farley		TIME COMPLETED:	04:35 PM

ALLEGATION(S):

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Due to lack of supervision, resident was inappropriately touched by another resident while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Toan Luong conducted a subsequent complaint visit to deliver findings for the above allegation. LPA met with Program Director Jennifer Farley and explained the reason for the visit.

On 07/06/2021, the Department received a complaint regarding an allegation of Neglect/Lack of Supervision. It was alleged that the facility does not have adequate supervision resulting in Resident 2 (R2) inappropriately touching other residents. Resident 1 (R1) does not consent to physical contact such as touching of the groin area, hugs, and kisses, yet R2 is seeking gratification through nonconsensual intimate relationship. The second allegation reported was that the facility staff are not providing a safe environment for residents. The complaint was referred to Community Care Licensing (CCL) Investigations Branch (IB) and assigned to Investigator Dennis Seng.
(Continued on 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022

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 4

Control Number 29-AS-20210706115410

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: 04/08/2022

NARRATIVE

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(Pg2) On 07/07/2021, from 12:40pm to 1:50pm, Licensing Program Analyst (LPA) Toan Luong conducted an initial 10 Day complaint inspection at Devereux - Casa Feliz. The visit was conducted on-site with Quality Management Manager (QMM) Leticia Villarreal and Assistant Clinical Director Clare Penny. During the visit, LPA Luong toured the facility with QMM and requested documents pertinent to the investigation. The LPA determined further investigation was required.

On 08/12/2021, Investigator Seng conducted an interview with Santa Barbara County Ombudsman; on 08/16/2021, with R1’s representatives; on 08/20/2021, with the facility clinical case manager; on 08/20/21, with staff and residents; and on 08/23/2021, with former staff and current staff.

Investigator Seng reviewed copies of facility records and University of California Santa Barbara (UCSB) Campus Police Incident Reports. R2’s diagnosis is listed as mild intellectual disability, cerebral palsy and seizure disorder. R2’s Individual Program Plan (IPP) dated 01/22/2021, states R2 exhibits the following disruptive social disorders: verbal hostility, resistiveness, self-injurious behavior with no apparent injuries, physical aggression toward staff and peers, and emotional outbursts. R2’s plan also states “it is important to R2 to have direct care staff one to one support and attention as often as R2 can”. Program Director Farley clarified that there is a section in the IPP that distinguish what is important to the resident versus what is important for the resident and the desire to have one to one support was that of R2s and not of the treatment team upon admission.

Investigator Seng reviewed incident reports from UCSB Campus Police. There were no reports filed for a sexual assault incident between R1, R2, and Resident #3 (R3), aside from two unrelated reports provided. The unrelated reports were related to R2 grabbing R3’s shirt. The other incident was related to R1 intervening as R2 had a behavior. All incidents from the reports were handled by Devereux administration as the police determined that no crime had occurred.

A review of the staff schedule reflected that there is one staff assigned to each shift – am, pm, and overnight. At the time the complaint was filed, there were a total of four (4) residents residing at the facility, two (2) of which had seizure disorders that require additional supervision, along with behaviors associated with their diagnoses. (Continued on 9099C)

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20210706115410

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: 04/08/2022

NARRATIVE

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(Pg3) Based on the information investigator obtained from interviews conducted, it was determined that R2 walked into the shower and bedrooms of R1 and R3. It appeared that staff did not put into place a plan of action and these incidents were allowed to continue due to consistent understaffing by the facility. After interviewing R1, the investigator determined R1 was inappropriately touched by R2. Per staff and victims’ statements, R2 also hugged and kissed both R1 and R3 repeatedly without their consent. R2 also admitted to asking both R1 and R3 to be their girlfriend. R1 and R3 both stated they did not consent to any of the physical contact initiated by R2. These statements were corroborated by multiple staff interviewed and by R2. Based on the evidence received from interviews and records, R2 had a history of walking into R1 and R3 bedrooms while they were changing and the bathroom as they showered. R2 walked into R1 and R3 showers and bedrooms and touched their groin and thigh area. Staff admitted that they are aware of these incidents and stated that this was due to a lack of staffing. Staff stated that due to the lack of staffing they were unable to adequately supervise the residents. In addition, per Program Director Farley, when R2 was admitted to the facility, the facility was not fully aware of the behaviors presented by R2 until as incidents occurred.

Due to multiple victims’ and staff statements it was determined R2 touched R1 and R3 inappropriately. Based on the multiple UCSB Campus Police Incident Reports, multiple victims’ and staff statements, there were also several incidents of physical assault that R2 perpetrated due to a lack of a staffing. The information obtained revealed these incidents occurred due to inadequate supervision.

The allegation Neglect/Lack of Supervision leading to R1 and R2 being hugged, kissed, and touched inappropriately by R2 is deemed Substantiated at this time, due to victim interviews, and staff being aware that R2 was going into R1 and R3 rooms and shower and continued to allow R2 to do this.

Exit interview conducted, deficiencies cited on 9099-D, appeal rights discussed, and a copy of this report issued.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 29-AS-20210706115410

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: 04/08/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/11/2022 Section Cited CCR 80078(a)	1 2 3 4 5 6 7	80078(a) Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement is not met as evidenced by:Based on interviews and records review, the licensee did not comply with	1 2 3 4 5 6 7	Licensee will submit plan how the facility will ensure there is adequate staffing to meet the needs of all residents. Submit to CCL by 4/11/22.
	8 9 10 11 12 13 14	the section cited above because several incidents, including physical assault and inappropriate touching were found due to poor supervision due to a lack of staffing, which posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
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	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 04/08/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022

LIC9099 (FAS) - (06/04)

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