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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850084
Report Date: 05/04/2022
Date Signed: 05/04/2022 03:55:36 PM

Document Has Been Signed on 05/04/2022 03:55 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:
05/04/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Chris PattonTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Toan Luong conducted an unannounced on-site visit to the facility in regards to an incident reports received from the facility. LPA was accompanied by Tri-Counties Regional Center Quality Assurance Specialist (TCRCQAS) Vincent Figueroa. LPA met with Administrator Chris Patton and explained the purpose of the visit.

Incident reports stated the following:

On 7/30/21, Staff gave C1 incorrect dosage of Clonidine. C1 was given .15 mg instead of .1 mg.

On 8/3/21 at 8:00 p.m., staff discovered 1 pill of Trazadone 100 mg remained in bubble pack for 8/2/21 8:00 p.m. dosage for C1.

On 1/2/22, staff did not provide C1 medication of Pregabalin 100 mg in the 8:00 a.m. period. Administrator conducted second check at 10:45 a.m. and verified that 8:00 a.m. dosage remained in bubble pack with noon dosage.

On 3/14/22, Staff discovered that C1 was provided incorrect dosage of Clonidine on 2/17/2022. C1 received .1 mg of Clonidine instead of .2 mg.

LPA reviewed Medication Administration Record (MAR) for dates 5/1/22 through 5/4/22 and medication bubble packs. MAR reflects the correct amount remained in bubble pack with one exception. One 12:00 p.m. medication was not in bubble pack due to C1 being on an outing. As such, item was not checked off. All other items were accurate.

Exit interview conducted with Administrator, report and appeal rights emailed to the administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE: DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2022
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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Document Has Been Signed on 05/04/2022 03:55 PM - It Cannot Be Edited


Created By: Toan Luong On 05/04/2022 at 11:27 AM
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: 05/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/05/2022
Section Cited
CCR
80075(b)

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80075 Health Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement was not met as evidence by: Based on interview and incident reports, the licensee did not comply with
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Staff have been removed from assistance with self-administration of medication until training was provided. Staff have been retrained. Bubble packs have been separated by morning, noon, evening, or bedtime dosages. PoC is corrected.
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the section above as multiple incident reports were submitted which poses an immediate health, safety, or personal rights risk to persons in care.
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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:Toan Luong
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2022


LIC809 (FAS) - (06/04)
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