425801744-7-22-2022-29-AS-KBUY-CGL2TC-20220722174030

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425801744
Report Date: 07/22/2022
Date Signed: 07/22/2022 03:06:24 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 Jeannette Olson

COMPLAINT CONTROL NUMBER: 29-AS-20210525130744

FACILITY NAME:	DEVEREUX CALIFORNIA - CASA FELIZ		FACILITY NUMBER:	425801744
ADMINISTRATOR:	KAREN DACOME		FACILITY TYPE:	735
ADDRESS:	6990 FALBERG WAY		TELEPHONE:	(805) 968-2525
CITY:	GOLETA	STATE: CA	ZIP CODE:	93117
CAPACITY:	7	CENSUS: 7	DATE:	07/22/2022
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Leticia Villarreal, Quality Management Manager via teams and Jennifer Farley, Program Director		TIME COMPLETED:	03:10 PM

ALLEGATION(S):

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Staff do not properly supervise resident
Staff do not report incidents to licensing

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Olson conducted subsequent visit to deliver final findings. LPA met with Leticia Villarreal, Quality Management Manager and Jennifer Farley, Program Director and explained the purpose of the visit.

LPA Luong conducted an initial complaint visit to the facility on 6/1/21 and met with Quality Management Manager (QMM) Leticia Villarreal. LPA conducted interviews and collected documents pertinent to the investigation. LPA Luong conducted interviews with staff on 6/1/21, 10/20/21, and 10/26/21. LPA reviewed May 2021 through July 2021 incident reports received by Community Care Licensing Division (CCLD).

On the allegation: Staff do not properly supervise resident. It was alleged that the facility does not provide supervision to clients when needed. LPA Luong’s interview revealed that Client #1 (C1) and Client #4 (C4) have seizures and require standby assistance in the shower. Staff are aware that C1 is diagnosed with Intellectual Development Disability. C1 has a history of aggression towards other clients. Continued on 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20210525130744

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: 07/22/2022

NARRATIVE

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C1 is also described by staff as needing a lot of attention and seeks a relationship with male clients. Staff informed LPA that there is typically 1 staff at Casa Feliz for 4 clients. Staff interviews also reveal that staff have lost track of C1 while assisting C4. C4 will require standby assistance while in the bathroom to prevent any accidents from seizures. In one instance, staff reported C1 wandered outside the facility and towards neighboring facilities. Staff also reported C1 has attempted to enter other client’s room without permission. Staff #3 (S3) reported C1 has entered Client #2’s (C2) room without C2’s permission and attempted to enter C4’s room while C4 was in the shower. Staff #7 (S7) also reported C1 has attempted to enter C4’s room prior to C4 showering. S7 attempted to redirect C1 out of the room, but C1 refused and wanted to watch C4 shower. S7 also reported that while S7 was assisting C4 in the bathroom for about 20 minutes, C1 left the facility. Staff #6 (S6) also reports C1 leaving the facility to go to a neighboring facility. LPA Luong reviewed May 2021 through July 2021 incident reports. Incident reports reported that C1 has several physical altercations with Client #3 (C3).

Based on interview and record review, there is 1 staff for the 4 clients. While staff is assisting other clients, staff are unable to supervise C1. The allegation Staff do not properly supervise resident is deemed substantiated.

On the allegation: Staff do not report incidents to licensing. It was alleged that the facility did not report incidents to CCLD. LPA Luong’s interview reveal that S7 reported an incident where C1 ran over C2’s foot with a walker. In the same day, C1 also attempted to scratch Client #3 (C3) but was redirected by S7. C1 then grabbed C4’s shirt and would not let go. S6 reported that C1 has attempted to kiss other clients. Other staff also reported C1 making comments that make C2 feel uncomfortable. All of these instances posed a risk to the personal rights, health and/or safety of the clients.

LPA Luong reviewed May 2021 through July 2021 incident reports as C1 was admitted to the facility May 2021. CCLD did not receive a report regarding C1 aggressing towards C2 nor C4. Based on interview and record review, multiple staff described incidents not reported to CCLD. The allegation Staff do not report incidents to licensing is substantiated.

Exit interview conducted, 9099-D, a copy of report and appeal rights were emailed to Administrator/Licensee

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20210525130744

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: 07/22/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/22/2022 Section Cited CCR 80078(a)	1 2 3 4 5 6 7	80078(a) Responsibility for Providing Care and Supervision. The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Facility has increased staff to supervise clients. POC cleared during visit.
	8 9 10 11 12 13 14	Based on interviews and records review, the licensee did not comply with 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
Type B 07/25/2022 Section Cited CCR 80061(b)(1)(E)	1 2 3 4 5 6 7	80061(b)(1)(E) Reporting Requirements…A written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event…Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.	1 2 3 4 5 6 7	Administrator agreed to submit a written statement of understanding and acknowledgement of 80061.
	8 9 10 11 12 13 14	Based on interviews and records review, the licensee did not comply with the section cited above because several incidents, including physical assault and inappropriate touching were not reported to CCL, which poses a potental health and safety risk to residents in care.	8 9 10 11 12 13 14

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: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2022

LIC9099 (FAS) - (06/04)

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