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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850084
Report Date: 07/10/2023
Date Signed: 08/10/2023 04:02:28 PM

Document Has Been Signed on 08/10/2023 04:02 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:
07/10/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Chris Patton, AdministratorTIME COMPLETED:
06:30 PM
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This is an amended report
Licensing Program Analyst (LPA) Jenny Olson arrived unannounced to conduct a one year annual continuation visit to this facility. LPA met with Chris Patton, Administrator and explained the purpose of the visit.

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.

Records: The LPAs reviewed client and staff records. LPA reviewed one (1) client file for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, and current needs and services plan. Admission agreement and personal rights records were missing.

LPA reviewed five (5) staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, current first aid certification. All files were complete.

Medications: Medications review began around 12:30 p.m.; medications are centrally stored and locked in a med cart in the office. Medications are labeled and checked for expiration dates. LPA advised the Administrator to ensure that all the necessary information is properly documented on the CSMDR.

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: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/10/2023
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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Document Has Been Signed on 07/10/2023 06:09 PM - It Cannot Be Edited


Created By: Jeannette Olson On 07/10/2023 at 05:23 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: 07/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in 1/5 staff does not have a valid first aid training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/12/2023
Plan of Correction
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Administrator agreed to get staff first aid trained and provide documentation to CCL by 7/12/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Kelly Burley
LICENSING EVALUATOR NAME:Jeannette Olson
LICENSING EVALUATOR SIGNATURE:
DATE: 07/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2023


LIC809 (FAS) - (06/04)
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