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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425802002
Report Date: 02/01/2023
Date Signed: 02/02/2023 02:29:09 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
02/08/2021 and conducted by Evaluator Kristin Kontilis
COMPLAINT CONTROL NUMBER: 29-AS-20210208140749
FACILITY NAME:DEVEREUX CALIFORNIA - SOMERSETFACILITY NUMBER:
425802002
ADMINISTRATOR:AMY WESTFACILITY TYPE:
735
ADDRESS:5554 SOMERSET DRTELEPHONE:
(805) 324-4833
CITY:GOLETASTATE: CAZIP CODE:
93117
CAPACITY:5CENSUS: 4DATE:
02/01/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff failed to treat residents with dignity and respect.
Staff failed to meet the residents' needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kristin Kontilis and Tracy Jackson, Lead Quality Assurance Specialist, Tri-Counties Regional Center conducted a subsequent complaint visit to deliver findings for the above allegations. LPA met with Ebony Brown, Program Administrator and explained the purpose of the visit. The facility is an Adult Residential Care facility to adults with developmental and intellectual disabilities. The facility contracts with Tri-Counties Regional Center. Staffing requirements are as follows: Staffing requirements are 2:1 for Client 1 (C1); 1 staff shared between Client 2 (C2) and Client 5 (C5); 1 staff for Client 3 (C3); 1 staff for Client 4 (C4).
On the allegation: Staff failed to treat residents with dignity and respect. It was alleged that Staff 1 (S1), Staff 2 (S2), and Staff 3 (S3) failed to treat residents with dignity and respect and were neglecting and abusing clients in care. RP states clients are being left unattended in the bathroom and common areas of the facility. RP states S1, S2, and S3 are ignoring clients by isolating themselves in the facility’s staff office with the staff door closed with no visual access to the kitchen, common area, or backyard patio and side patio of the
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Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023
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 6
Control Number 29-AS-20210208140749
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 - SOMERSET
FACILITY NUMBER: 425802002
VISIT DATE: 02/01/2023
NARRATIVE
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facility. RP states S1, S2, and S3 make inappropriate comments that lack dignity and/or respect to clients. Such comments include derogatory references of clients’ appearance and behavior. RP states S2 stated to Client 2 (C2) that C2’s pimples were gross and started “popping” C2’s pimples. RP states Amy West, Program Administrator (PA) issued a facility staff memorandum (“memo”) to all staff regarding the proper manner in which to treat the clients in care. RP states S1, S2, and S3 did not follow the memo and claimed it to be “stupid” and “useless”. Records reviewed and interviews conducted revealed on 1/31/2021 during a 7 am – 3 pm shift, S1, S2, and S3 were in the staff office for long periods of time, leaving only one staff member supervising and attending to 4 of the 5 clients’ needs for large periods of time. Records reviewed revealed on 2/3/2021, S3 was assigned to providing care and supervision to C2 however at that time, S1, S2, and S3 were in the facility staff office for at least 30 minutes during breakfast time leaving C2 to be provided breakfast by another staff member who was not assigned to C2, and not in accordance with required staffing ratios. Records reviewed revealed when S3 exited the staff office, S3 “got mad” that C2 had been given breakfast because S3 had planned on taking C2 out to get coffee. Records reviewed and interviews conducted revealed on 2/8/2021, S1, who was assigned to Client 3 (C3), was spending time on S1’s personal phone ‘Facetiming’ with family. S1 left the facility at approximately 9:00 or 9:30 pm stating C3 was asleep. Records reviewed and interviews conducted revealed C3 was not asleep and C3 was active throughout the facility. On 2/11/2021, C2 was “exhibiting precursor and challenging behaviors “(anxious, pacing, slamming doors, taking clothes off, hitting self)”. S1 was observed to repeatedly tell C2 to “sit down”, “get out” “kitchen closed”, “stop yelling” “you don’t even know what you want”, “just go to bed already”, then S1 locked the bathroom door to prevent C2 from using the bathroom. Records reviewed and interviews conducted revealed on 2/10/2021, S1 was heard to say C1 needed to be restrained and did not need to report the restraint because it was only one time and only lasted a few minutes. On 2/12/2021, staff observed C2 to have a ‘Self-Injurious Behavior’ (SIB) injury. Records reviewed revealed on 2/12/2021, PA went to the facility to inquire about an injury C1 had from what appeared to be a SIB. During the inquiry, it was reported to PA that the previous day staff had been derogatory and disrespectful to the clients, and the individual making this statement believed the staff’s behavior was a contributing factor to C1’s behavior and that there were more challenging behaviors when certain staff were working. Records reviewed and interviews conducted revealed on 2/14/2021, S2 was observed to grab C2 and pulled C2 down to sit in a chair; when C2 did not sit down, it was observed that S2 stated “you don’t need to eat more”, “you’re fat”, then S2 grabbed C2’s stomach and wiggled it in S2’s hand.

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SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20210208140749
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 - SOMERSET
FACILITY NUMBER: 425802002
VISIT DATE: 02/01/2023
NARRATIVE
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Records reviewed and interviews conducted revealed on 2/15/2021, Amy West, Program Administrator, Jennifer Farley, Program Director, and Veronica Arenas-Soto, People Operations Director, held a meeting with S1, S2, and S3 to discuss job performance concerns including attitudes, staying in the staff office while on shift, speaking negatively about the Devereux organization, the clients, and the Program Administrator; being dismissive, ignoring the clients, being “untherapeutic” with the clients, ignoring requests, telling people “no”, being on their personal phones and using “Facetime” while at work, and reports of using restraints before using all de-escalation techniques. Records reviewed and interviews conducted further revealed that during the 2/15/2021 meeting with S1, S2, and S3, S1, S2, and S3 were reminded that all incidents using restraints are to be reported via a “Serious Injury/Serious Illness Report (SIR)”; S1, S2, and S3 were told they were creating an environment where people didn’t want to work with them when they were on shift and they were not allowed to work their shifts together. Records reviewed and interviews conducted revealed on 2/16/2021, S1, S2, and S3 were overheard making comments to C1 such as “you’re ugly”, “ew your face is so gross, you have so many pimples”, then S2 would “pop” C1’s pimples; C1 was told “do it yourself, I’m not your maid”, “we’re going to have a good day or else”. Records reviewed revealed on 2/16/2021, S1, S2, and S3 were heard to make statements of “you’re dumb”, “you’re ugly”, and “you’re stupid” directed to C2. When C2 showed behaviors of “anxiousness and being vocal”, S1, S2, and S3 repeatedly in a rude manner told C2 to sit down and stated, “you’re so annoying”.

During the investigation, LPA and Tracy Jackson, QAS, Tri-Counties Regional Office conducted interviews with staff and reviewed relevant documents. On 2/17/2021, an interview conducted with Amy West, Program Administrator (PA) revealed that West had knowledge of the neglect and abuse concerns. West stated after the concerns were brought to her attention, on 2/4/2021 a memo was posted at the facility giving specific instructions to staff stating staff should not be “hanging out” in the facility staff office, talking about personal issues, talking on personal phones, watching videos, or using the internet for “personal reasons”. The memo provided specific protocol stating if a staff member needed to retrieve something from the office, the staff member needed to have another staff member supervise their client and it should only be a 2-3 minute interval indicating to staff “This is a care critical issue.” The memo specifically states “Neglecting the staff is exactly that, NEGLECT, and is reportable as ABUSE. The [clients] deserve your full attention.” The memo provides specific direction to Staff in Charge (SIC) stating ‘SIC should not be in the office throughout the entire shift; should help direct the staff, make sure the

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SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 29-AS-20210208140749
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 - SOMERSET
FACILITY NUMBER: 425802002
VISIT DATE: 02/01/2023
NARRATIVE
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staff and the [clients] are engaged, preparing for future activities, helping break staff, ensure cleaning and chores are done, ensuring hygiene is being done, etc…There is really no shortage of things to do.’ According to the investigation, after the posting of the memo S1, S2, and S3 continued to isolate themselves in the staff office, verbally abuse the clients in care, leave client(s) unattended, and demonstrated disregard for the staff memo. During PA’s interview on 2/17/2021, the PA admitted that she did not send in incident reports about the verbal abuse and neglect to CCL or Tri-Counties Regional Center. PA stated ‘more should have been done’ to self-report the reports of suspected neglect and abuse to CCLD and S1 “should not be SIC”. PA further stated there is an investigation into the conduct of S1, S2, and S3 at this time. Records reviewed and interviews conducted revealed on 2/17/2021, S1, S2, and S3 were removed from their shifts and placed on administrative leave. During PA’s and PD’s interviews on 2/17/2021, a concern was raised as to the amount of time PA has been spending at the facility as the Administrator in Charge. On 2/17/2021, Tracy Jackson, Lead QAS, Tri-Counties Regional Center (TCRC) and LPA Kontilis discussed with PA and PD working “online” or as a Direct Support Professional (DSP) does not constitute working as an “Administrator” and per TCRC’s program plan and the facility’s plan of operation, West is required to be at the facility monitoring what is going on at least twenty (20) hours/week as the Program Administrator.

Based on the information obtained, the allegation Staff failed to treat residents with dignity and respect is deemed Substantiated at this time.

On the allegation: Staff failed to meet the residents’ needs. It was alleged that S1, S2, and S3 are ignoring clients by isolating themselves in the facility’s staff office with the staff door closed with no visual access to the kitchen, common area, or backyard patio and side patio of the facility. Records reviewed and interviews conducted revealed on 1/31/2021 during a 7 am – 3 pm shift, S1, S2, and S3 were in the staff office for long periods of time, leaving only one staff member supervising and attending to 4 of the 5 clients’ needs for large periods of time. Records reviewed revealed on 2/3/2021, S3 was assigned to providing care and supervision to Client 2 (C2) however at that time, S1, S2, and S3 were in the facility staff office for at least 30 minutes during breakfast time leaving C2 to be provided breakfast by another staff member who was not assigned to C2, and not in accordance with required staffing ratios. Records reviewed revealed when S3 exited the staff office, S3 “got mad” that C2 had been given breakfast because S3 had planned on taking C2 out to get coffee. Records reviewed and interviews conducted revealed on 2/3/2021, concerns were voiced to PA that there was a pattern of aggression and Self-Injurious Behaviors (SIBs) when certain staff are working

Please continue to 9099-C, Pg 5.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20210208140749
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 - SOMERSET
FACILITY NUMBER: 425802002
VISIT DATE: 02/01/2023
NARRATIVE
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(including S1, S2, S3) and the issues are not being taken seriously. Records reviewed and interviews conducted revealed on 2/8/2021, S1, who was assigned to C3, was spending time on S1’s personal phone ‘Facetiming’ with family. S1 left the facility at approximately 9:00 or 9:30 pm stating C3 was asleep. Records reviewed and interviews conducted revealed C3 was not asleep and C3 was active throughout the facility. On 2/11/2021, C2 was “exhibiting precursor and challenging behaviors “(anxious, pacing, slamming doors, taking clothes off, hitting self)”. S1 was observed to repeatedly tell C2 to “sit down”, “get out” “kitchen closed”, “stop yelling” “you don’t even know what you want”, “just go to bed already”, then S1 locked the bathroom door to prevent C2 from using the bathroom.

The clients’ needs were not met when staff isolated themselves in the office and did not provide supervision to clients per the ratios; when S1 ‘Facetimed’ their family while they were supposed to be supervising C3; when S1 left the facility stating C3 was asleep when C3 was not asleep; when S1 told C2 the kitchen was closed and when they locked the bathroom door to prevent C2 from using the bathroom. Based on the information obtained, the allegation Staff failed to meet the residents’ needs is deemed Substantiated at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D):

Exit interview conducted. Copy of report, Appeal Rights and Civil Penalty issued.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20210208140749
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 - SOMERSET
FACILITY NUMBER: 425802002
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/03/2023
Section Cited
CCR
80072(a)(1)
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80072(a)(1) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: To be accorded dignity in his/her personal relationships with staff and other persons. This requirement is not met as evidenced by:
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POC: Program Administrator (PA) agrees to conduct personal rights training for all staff. PA will submit detailed description of training, attendees (first and last names), person conducting training. Details of training will be sent to LPA via email.
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Based on interviews conducted and record review, the licensee did not comply with the section cited above, as the licensee did not ensure S1, S2, and S3 accorded clients dignity, which poses an immediate personal rights risk to clients in care.
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Type A
02/03/2023
Section Cited
CCR
80078(a)
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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:
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POC: Administrator agrees to train all staff on supervision expectations. PA will submit detailed description of training, attendees (first and last names), person conducting training. Details of training will be sent to LPA via email.
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Based on interviews conducted and record review, the licensee did not comply with the section cited above, as the licensee did not provide adequate supervision to clients on multiple occasions, which poses an immediate health and safety risk to clients in care.
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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.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6