<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850084
Report Date: 05/04/2022
Date Signed: 05/04/2022 03:57:39 PM

Document Has Been Signed on 05/04/2022 03:57 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:
12:00 PM
MET WITH:Chris PattonTIME COMPLETED:
04:10 PM
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) Toan Luong conducted an unannounced on-site visit to the facility in regards to an incident report received from the facility. LPA was accompanied by Tri-Counties Regional Center Quality Assurance Specialist (QAS) Vincent Figueroa. LPA met with Administrator Chris Patton and explained the purpose of the visit.

LPA and QAS conducted interviews on 4/26/22, 4/28/22, and on 5/4/22 with witnesses and staff.

It was alleged in the incident report completed 4/22/22 that staff had inappropriately restrained Client #1 (C1).

Interviews reveal Staff #2 (S2) had held C1's wrist together in order to have C1 drop S2's personal belonging. S2 was unaware that grabbing C1's wrist constitutes as a restraint. The facility's procedure would have staff only intervene physically if a client was in danger to self or others. C1 was sitting by C1's self at the time and had been engaging in self-injurious behavior (SIB) prior taking possession of S2's belonging. Once C1 had S2's belonging, C1 was not a threat to self nor others. LPA issued citation on 809D.

LPA conducted exit interview with Administrator and emailed a report along with appeal rights to 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)
Page: 1 of 2
Document Has Been Signed on 05/04/2022 03:57 PM - It Cannot Be Edited


Created By: Toan Luong On 05/04/2022 at 11:45 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
85102(b)(2)

1
2
3
4
5
6
7
85102 Emergency Intervention Prohibitions
(b) Manual restraint or seclusion shall not be used: (2) For the convenience of staff. This requirement was met as evidence based off interviews, staff held client's wrist together to
1
2
3
4
5
6
7
Staff involved have taken personal rights risk training and S$PA 1,2,3 and PEIT. POC has been corrected.
8
9
10
11
12
13
14
retrieve staff's personal belongings when client was not a threat to self or others which poses an immediate health, safety, or personal rights risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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)
Page: 2 of 2