425850084-9-1-2022-29-AS-JOLN-CHUPG8-20220901111756

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425850084
Report Date: 09/01/2022
Date Signed: 09/01/2022 11:18:31 AM

Document Has Been Signed on 09/01/2022 11:18 AM - 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 - TULAROSA		FACILITY NUMBER:	425850084
ADMINISTRATOR:	PATTON, CHRISTOPHER		FACILITY TYPE:	737
ADDRESS:	1855 TULAROSA ROAD		TELEPHONE:	(805) 879-0357
CITY:	LOMPOC	STATE: CA	ZIP CODE:	93436
CAPACITY: 3		CENSUS: 1	DATE:	09/01/2022
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Chris Patton, Administrator Via Telephone		TIME COMPLETED:	11:30 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Olson conducted a follow up visit to deliver final findings for an incident that occurred on 07/04/2022 that the facility self reported in an Incident Report (IR). LPA was accompanied by Tri-Counties Regional Center Quality Assurance Specialist (QAS) Vincent Figueroa. LPA and QAS interviewed staff on 7/15/22, 7/19/22, 7/21/22, 7/27/22, and 8/3/22. LPA and QAS interviewed Client 1’s (C1) Conservator and Service coordinator on 7/15/22, 8/5/22, and 8/17/22. LPA and QAS met with Administrator Chris Patton over the phone, Meagan Kruger and Ana Jimenez and explained the purpose of the visit. Client 1 (C1) has a conservatorship where the conservator has full rights over C1 including placement and visitation. On 06/17/2022 a new Visitation and Communication Guidelines for C1’s family members was updated. The Guidelines state on 6/1/22 C1’s Family Member 1 (FM1) is permitted to have regular unscheduled visits but C1 must have 2:1 staff ratios during the visit. Licensing received an incident report on 07/07/2022 regarding an incident that occurred on 07/04/2022. The incident report stated that 3 staff (Staff 1, Staff 2, and Staff 3) were present during the home visit with FM1 when C1 got in a jacuzzi, took out their private parts and may have started masturbating. FM1 entered the jacuzzi and C1 asked for help, and gave FM1 a picture to hold. FM1 stood behind C1 holding the picture as C1 leaned into the jets. Staff immediately contacted Administrator via telephone, the telephone was given to FM1 who then got out of the Jacuzzi and went inside the house. Interviews revealed FM1 sent an email to the team asking if “we are on for 4^th of July visit” but was informed the visit would not take place at Family Member 2 (FM2)’s house. On 07/01/2022 an email confirmed that there will be a visit at another family member’s house on 07/04/2022 from 10 AM-12 PM. Continued on 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022

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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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 - TULAROSA	FACILITY NUMBER: 425850084
	VISIT DATE: 09/01/2022

NARRATIVE

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Interviews with Staff 1 on 7/15/22, Staff 2 on 07/19/2022 and Administrator on 07/21/2022 revealed that they had no prior knowledge of there being a jacuzzi at the house that would be visited. An interview with Staff 3 on 07/19/2022 revealed that C1 initiated a call to FM1 on 07/01/2022 regarding the visit. Staff remembered 3 staff being present (Staff 3, Staff 4 and Staff 5) during the call. C1 asked FM1 if they would be going to the Jacuzzi. Staff 3 stated that FM1 responded they were going to a family member’s house and repeated the address multiple times. FM1 then listed activities they would be doing such as: the jacuzzi would be warm and ready and there were some movies from the library for C1 to watch. Staff remembered FM1 asking C1 what they wanted to eat. C1 stated they wanted pizza from Little Caesars but FM1 stated they would be having BBQ with hot dogs and hamburgers. S3 stated that after the call C1 had some Self-Injurious Behaviors and repeated “Little Caesars” multiple times. LPA interviewed Staff 4 regarding the call. Staff 4 confirmed they were the Staff in Charge (SIC) and remembered the call happening. Staff 4 provided a text they sent to Administrator Chris Patton on 07/01/22 at 6:19 PM stating “Hi Chris, (C1) is having a phone call with [FM1] and [FM1] mentioned something about having a jacuzzi at [the house being visited] just wanted to see let you know.” Administrator responded, “Yes please write a statement of what was said,” and Staff 4 wrote a declaration. Interviews also revealed that Staff 3 was told to write a declaration regarding the call on 07/05/2022. LPA interviewed a total of 9 staff asking what wording prompts a “declaration of facts” for C1. Not all staff had the same answer. For example, Staff 5 did not write a declaration about the phone call on 07/01/2022 because they were told it is only required when the conversation is in regards to FM2 and a jacuzzi.

On 08/03/2022 LPA Olson visited the facility where Administrator apologized for forgetting about the text conversation with Staff 4 on 07/01/2022. Administrator stated that the visit would still have most likely proceeded even though a jacuzzi would be present. Interview with C1’s Conservator revealed that they wish they knew about the jacuzzi prior to the visit and they would have made additional changes to ensure C1 was safe and had appropriate interactions during the visit. Although the facility was not in direct violation of the Visitation Guidelines, it would have been a best practice for the Administrator to alert the Conservator that there would be a jacuzzi at the house where the visit was taking place. No citations will be issued at this time as a result of this incident, but the Administrator was counseled about ensuring C1’s health and safety, ensuring accurate and timely communication with C1’s Conservator, and using good judgment.
Exit interview, report given.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022

LIC809 (FAS) - (06/04)

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