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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801744
Report Date: 04/22/2022
Date Signed: 04/22/2022 02:33:48 PM

Document Has Been Signed on 04/22/2022 02:33 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: DATE:
04/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Leticia VillarrealTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Toan Luong conducted an unannounced One Year Infection Control Annual visit to the facility. LPA met with Staff (S1) Josie Fernandez and explained the purpose of the visit. LPA subsequently met with Quality Management Manager (QMM) Leticia Villarreal and explained the purpose of the visit.

LPA was screened at the administration office prior to entering the facility. Program Director Jennifer Farley approved S1 to tour the facility with LPA and sign report. At 11:40 a.m., LPA entered the medication room as the top portion of the dutch door was open. LPA then opened an unlocked drawer containing routine and PRN medication for a client. Staff was not present when LPA entered the medication room. LPA informed S1 that centrally stored medication needed to be locked and accessible only to employees responsible to centrally stored medication. S1 locked the cabinet and dutch door. LPA issued citation on 809D. At 11:50 a.m., LPA observed the wall across the medication room having paint chips falling off and was able to view the intersections of the plywood. LPA issued a technical advisory. LPA observed several window screens that were not in good conditions as one had a hole the size of a golf ball, few others had dents, and one had grass debris. LPA issued technical advisory. LPA discussed items in the Infection Control Module and noted that the facility had handwashing signs in one of two the bathrooms. The facility did not have Covid signage posted throughout the facility but all signs were posted outside the facility or on the window of the medication room. QMM had staff post signs throughout facility prior to LPA's departure. Infection Control module was addressed with QMM to satisfaction.

LPA conducted exit interview with QMM and emailed a copy of today's report and appeal rights to the QMM.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE: DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 04/22/2022 02:33 PM - It Cannot Be Edited


Created By: Toan Luong On 04/22/2022 at 12:48 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: 04/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
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:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in 1 count for 1 of 7 clients, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2022
Plan of Correction
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QMM informed LPA that staff was distracted due to client outburst and LPA's visit. Staff forgot to lock the door. QMM will send LPA an email that staff was informed to secure medication room prior to leaving. Due date by 4/25/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Toan Luong
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2022


LIC809 (FAS) - (06/04)
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