425850084-5-16-2023-29-AS-JOLN-CRW2JQ-20230516172642

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425850084
Report Date: 05/16/2023
Date Signed: 05/16/2023 05:27:47 PM

Document Has Been Signed on 05/16/2023 05:27 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 - 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:	05/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Meagan Kruger, Board Certified Behavioral Analyst (BCBA) and Chris Patton, Administrator		TIME COMPLETED:	05:45 PM

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Licensing Program Analyst (LPA) Jenny Olson arrived unannounced to conduct a one year required annual visit. LPA met with Meagan Kruger, Board Certified Behavioral Analyst (BCBA) and Jennifer Farley, Program Director over the phone and explained the purpose of the visit. Administrator Chris Patton arrived to the facility around 3:30pm.

LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Kitchen: The kitchen area was observed around 12:00 p.m. The facility has a sufficient supply of non-perishable and perishable food items. Cleaning supplies and disinfectants are stored under the sink locked, inaccessible to clients. Knives are stored in a locked drawer in the kitchen.

Common areas: Living and dining room furniture were observed to be in ok condition. There was a small rip in the couch cushion and stain on the couch. At 3:15 p.m., smoke detector(s) and carbon monoxide detectors were tested and operational at the time of the visit. The fire extinguishers were charged and serviced 3/17/2023.

The backyard has a lattice covered outdoor area equipped with furniture for client use. No bodies of water noted. The washer and dryer are in the laundry room.

Restrooms: The two client restrooms were clean and sanitary and in operating condition with non-skid surfaces. The bathrooms were sufficiently stocked with soap and paper towels. Around 2:30 p.m., the hot water temperature measured in the client restroom at 112.7 degrees Fahrenheit.

Bedrooms: There are three (3) client rooms, which were furnished with appropriate linens and required furniture. The laundry room was stocked extra linens and towels.

Continued on 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

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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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: 05/16/2023

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The facility is vendored by Tri-Counties Regional Center (TCRC) as a EBSH home. The last disaster drill was conducted on 4/15/2023.

Infection Control: The facility has an infection control plan The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. The facility has single rooms and can isolate clients if the facility has a confirmed case of COVID-19.

Due to time constraints LPA was unable to finish the annual and will return at another date to continue the annual inspection.

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

Exit interview conducted. A copy of the report and appeal rights was issued.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/16/2023 05:27 PM - It Cannot Be Edited

Created By: Jeannette Olson On 05/16/2023 at 04:36 PM

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 - TULAROSA	FACILITY NUMBER: 425850084
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85161(b)

Emergency Intervention Documentation and Reporting Requirements

(b) Each use of manual restraint or seclusion shall be reported to the Department in writing no later than the next business day. This time frame shall supersede the reporting time frame required by Section 80061(b). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in when restraints were not reported for 48 hours, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/23/2023
	Plan of Correction
1 2 3 4	Administrator agreed to submit a statement of understanding of regulation 85161 and a plan to ensure manual restraints are reported in writing no later than the next business day to CCL by 5/23/23.

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: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

LIC809 (FAS) - (06/04)

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