425801744-2-27-2023-29-AS-JOLN-CPFRVA-20230227122114

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425801744
Report Date: 02/27/2023
Date Signed: 02/27/2023 12:21:50 PM

Document Has Been Signed on 02/27/2023 12:21 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 FELIZ		FACILITY NUMBER:	425801744
ADMINISTRATOR:	JOEL GOFORTH		FACILITY TYPE:	735
ADDRESS:	6990 FALBERG WAY		TELEPHONE:	(805) 968-2525
CITY:	GOLETA	STATE: CA	ZIP CODE:	93117
CAPACITY: 7		CENSUS: 7	DATE:	02/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Antonela Milito, Program Administrator		TIME COMPLETED:	12:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) Olson conducted an on-site 1 year infection control annual visit to the facility above on 2/27/2023 around 10:00 AM. LPA met with Antonela Milito, Program Administrator and explained the purpose of the visit.

LPA took a physical plant tour of the facility with Staff. The facility has submitted an Infection Control Plan to the department. The facility has an entry point at the side door where everyone entering signs in after completing a temperature screening on all staff and visitors at the office for those who want to come into the facility. The entry station has hand sanitizer. The staff screen residents for symptoms and temperature as needed. Increased monitoring is conducted if any change of condition are noted or any residents are showing any signs, symptoms or a temperature. Staff makes sure residents have a mask when leaving the facility on outings into the community. All staff will wear face coverings in the facility and when on outings with residents. Facility has areas for visiting inside and outside. The facility also offers virtual and telephone communications to all residents in care. Staff, Residents and visitors are informed of the facilities infection control policies. New residents will be tested and negative results received before working or residing in the facility. The facility has procedures and plans for screening, isolation, testing, when to call 911 and notifying all responsible parties and agencies when needed.

Administrator is in charge of infection control and provides training and education to staff, residents and visitors. Staff will use full PPE with N95 masks and face shields when working with any pending or confirmed cases of Covid-19. Facility is able to dedicate a single room for residents so isolation can be arranged when and if needed. The facility has single rooms and they are disinfected and wiped down daily. Precautionary Droplet signs will be posted on any room with quarantine or isolated individuals. PPE supplies will be located right outside those rooms when required. Facility has a 30 day supply of PPE on hand.

Continued on 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2023

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 02/27/2023 12:21 PM - It Cannot Be Edited

Created By: Jeannette Olson On 02/27/2023 at 11:02 AM

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: 02/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above when the couch and trash cans were not in good repair, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/13/2023
	Plan of Correction
1 2 3 4	Back up Administrator agreed to fix or replace the couch and trash cans and submit pictures to CCL by 3/13/23

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Jeannette Olson

LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2023

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 02/27/2023

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Facility has plans for delivering medications and meals to any quarantined/isolation resident rooms. Facility has a plan in place for when and whom to notify in an outbreak or other emergencies. Administrator will keep a line list of all vaccinated and tested staff/residents in care with dates/results.

Facility has conducted training on infection prevention, symptoms, transmission and PPE use. Facility has non-punitive sick leave polices for staff. Sick staff are requested to stay home and not report to work if ill. Residents medication is delivered in 30 day supplies to the facility. The facility ensures proper cleaning is done on frequently touched surfaces and between any individuals sharing of space or items. Sinks were well stocked with soap, and paper towels. Staff and resident records are kept in a locked office. Facility does realize guidance changes and the most up to date guidance from CCL-PINS, CDC, CDPH, and local health departments should be followed to remain in compliance. Fire extinguisher was charged and inspected annually. The facility has working smoke and carbon monoxide detectors present in the facility.

At approximately 11:30 am, LPA reviewed Department of Social Services, Community Care Licensing Division, Licensing Information System (LIS)/Guardian, Facility Personnel and facility staff roster and determined that all staff are fingerprint cleared and associated to the facility.

At approximately 10:15 AM LPA observed couch cushions to be ripped and have stuffing coming out.

At approximately 10:45 AM LPA observed trash can lids to be broken and not properly adhered to the trash cans.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).

Exit interview completed copy of report and appeal rights was emailed and printed

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2023

LIC809 (FAS) - (06/04)

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