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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425850084
Report Date: 04/11/2022
Date Signed: 04/11/2022 01:34:07 PM

Unsubstantiated


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
04/08/2022 and conducted by Evaluator Toan Luong
COMPLAINT CONTROL NUMBER: 29-AS-20220408111152
FACILITY NAME:DEVEREUX CALIFORNIA - TULAROSAFACILITY NUMBER:
425850084
ADMINISTRATOR:PATTON, CHRISTOPHERFACILITY TYPE:
737
ADDRESS:1855 TULAROSA ROADTELEPHONE:
(805) 879-0357
CITY:LOMPOCSTATE: CAZIP CODE:
93436
CAPACITY:3CENSUS: 1DATE:
04/11/2022
UNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Ana Jimenez and Chris PattonTIME COMPLETED:
01:50 PM
ALLEGATION(S):
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Staff did not prevent client from sustaining an injury while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Toan Luong conducted an unannounced complaint visit to the facility. LPA met with Staff in Charge (S1) Ana Jimenez and explained the reason for the visit. At 1:00 p.m., LPA met with Administrator Chris Patton. LPA toured the facility.
Between 10:55 a.m. to 1:00 p.m. LPA interviewed staff and client. LPA reviewed Data Collection Sheet for dates 4/3/22 and 4/5/22, Medication Administration Record (MAR) page for the month of April 2022, and Indvidual Body Check sheets dates 3/26/22 through 4/10/22. Interviews among staff reveals that Client #1 (C1) engages in Self Injurious Behavior (SIB) to the arm, forehead, and eyes frequently. Incident reports submitted to Community Care Licensing and Indvidiual Body Check Sheets corroborates staff statements. Incident report received indicated that on 4/5/22, C1 engaged in SIB 2 and a PRN was approved the by Program Administrator (PA) Chris Patton. C1 continued SIB and engaged in property destruction. An additional request for PRN was requested by staff and approved by PA. Individual Body Check Sheet for 4/5/22 indicated that C1 engaged in SIB to the eye and arm. Sheet also indicated C1's neck was red.(Continued on 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2022
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 2
Control Number 29-AS-20220408111152
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 - TULAROSA
FACILITY NUMBER: 425850084
VISIT DATE: 04/11/2022
NARRATIVE
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LPA reviewed MAR and noted that Clonidine .1mg and Saphris 2.5 mg was provided to C1 on 4/5/22. Per MAR, Saphris is given to C1 only after Clonodine was given to prevent further SIB. Hydrocortisone is also taken by C1 as a PRN on 4/6/22 and 4/7/22. Side effects may include additional swelling and redness. Collection Data Sheet for 4/5/22 reports that C1 engaged in SIB 1 four times, SIB 2 once, SIB 3 thrice, aggression 1 thrice, aggression 2 twice, aggression 4 five times, and property destruction 2 six times. Staff interviews reveal that when C1 engages in SIB, staff will implement coping strategies such as asking C1 to breath deeply or count. Interviews with staff reveal that on 4/5/22, C1 engaged in SIB 2 to the eye and PRN Clonidine was provided to C1 after PA approval. C1 engaged in SIB 3 and property destruction. Coping strategies implemented by staff was not successful. Staff consulted with PA, and PA approved Saphris 2.5 mg. C1 disengaged in SIB afterwards. Interviews among staff noted that C1's eye was red and swollen. One staff reported the following day C1 did have a black eye. Interviews with staff also reveal, staff do not physically intervene with C1 unless immediate danger is presented to self.
Based on record review and interview, the above allegation is deemed to be unsubstantiated.

Exit interview was conducted and a copy of the report was emailed to the program administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2