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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850084
Report Date: 08/26/2022
Date Signed: 08/26/2022 03:38:36 PM

Document Has Been Signed on 08/26/2022 03:38 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 - TULAROSAFACILITY NUMBER:
425850084
ADMINISTRATOR:PATTON, CHRISTOPHERFACILITY TYPE:
737
ADDRESS:1855 TULAROSA ROADTELEPHONE:
(805) 879-0357
CITY:LOMPOCSTATE: CAZIP CODE:
93436
CAPACITY: 3CENSUS: 1DATE:
08/26/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Chris Patton, AdministratorTIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Olson conducted an unannounced on-site visit to the facility in regards to an incident that occurred on 8/20/2022. LPA was accompanied by Tri-Counties Regional Center Quality Assurance Specialist (QAS) Vincent Figueroa and Department of Developmental Services Behavior Specialist II Carmen Ruiz-Ochoa. LPA QAS and DDS met with Meagan Kruger, Board Certified Behavioral Analyst (BCBA) and explained the purpose of the visit. Administrator Chris Patton arrived to the facility around 11:30 AM.

LPA, QAS, and DDS toured the inside and outside of the facility with BCBA and Staff in Charge SIC Carleen Prado and reviewed documents pertaining to Client 1.

LPA QAS and DDS interviewed Administrator and BCBA regarding the incident and best practices surrounding PRNs and restraints. LPA, QAS, and DDS requested relevant documents. At this time, further investigation is needed. LPA will follow up at a later date to continue the investigation.

Exit interview conducted and a copy of the report emailed to the administrator/licensee.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2022
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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