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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850084
Report Date: 01/08/2024
Date Signed: 01/08/2024 02:50:55 PM

Document Has Been Signed on 01/08/2024 02:50 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: 3DATE:
01/08/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Chris Patton, AdministratorTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Manager (LPM) Kelly Burly, Licensing Program Analysts (LPA’s) Jenny Olson and Erika Miller conducted a Case Management - Deficiencies visit to the facility above. LPM and LPAs met with Administrator, Chris Patton and explained the purpose of the visit. These deficiencies were observed by Department of Developmental Services during a visit conducted 12/20/23. CCL and Regional Center staff were also present during the visit.

According to records, Client 1 (C1) had no recorded bowel movements (BMs) from 11/18/23 to 11/26/23 and 12/1/23 to 12/9/23. C1 has a PRN order for “Dulcolax 5mg 2 tabs by mouth daily as needed for constipation. Max 1 dose/24 hour.” There was no PRN given in November, and the facility’s PRN sheet for December does not have the order for Dulcolax. C1’s medication was not given as prescribed.

According to records, Client 2 (C2) C2 had no BM’s recorded between 11/7/23 to 11/14/23 and 11/29/23 to 12/09/23, yet no PRNs were given. C2 had a PRN order “give Magnesium Citrate one bottle for 2 days if no BM’ and “Polyethylene Glycol Powder give 17gm by mouth at bedtime as needed for no BM for 2 days.” No PRN was given in the month of November and December, therefore C2’s medication was not given as prescribed. Side effects for C2’s Clozapine 100 mg PO daily indicate constipation as a side effect. Staff interviewed stated they had no training or knowledge of residents’ bowel issues or PRN orders, or adverse side effects to medications to watch for.

Client 3 (C3) had a physician’s order for “Polyethylene Glycol 17gm mix with 1 capful water/juice/tea given by mouth daily for constipation.” However the facility wrote it in their MAR and PRN sheet as a PRN order, instead of a daily medication.

Continued on 809-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE: DATE: 01/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/08/2024
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: 01/08/2024
NARRATIVE
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 It was also noted the bowel movement log stated C3 had no BM’s between 11/6/23 to 11/10/23, 11/14/23 to 11/18/23, and 11/25/23 to 12/13/23 but only received a PRN for constipation on 11/4/23, 12/16/23, and 12/19/23. According to the physician’s order and BM log, C3’s medications were not given as prescribed.

In response to the medication errors observed, Administrator indicated clients had BMs and did not require medical attention, but the BMs were not documented appropriately on multiple occasions. This has since been resolved.

It was also discovered that the facility was not following their program plan in the following areas: The facility has no health care plan for clients per their program plan; Staff were not trained on clients’ health care plans per the program plan; The facility Medication Administration Record (MARs) are not reviewed by the RN or Program Administrator as outlined in the Program Plan.

Additionally, CCL received an incident report on 12/16/23 stating that on 12/13/23 Staff 1 did not provide C3 their Clonazepam 2mg at 5pm. Staff 1 was removed from assisting with medication until recertifying the medication administration process.
CCL received an incident report on 1/5/24 stating that on 1/3/24 C3 was given their 2pm Clonezepam 1mg at 1:03pm by staff 2 (S2) and then re-given their Clonezapam 1mg by Staff 3 (S3) at 3:45pm. Staff 3 was removed from assisting with medication until recertifying the medication administration process.

LPA Olson provided Technical Assistance in regards to the following issues observed during the visit: It was observed that the facility did not have an organized system for maintaining documentation of all medical/health information in the client’s file. LPA recommended an improved system of organization be implemented in regards to the files.

At 1:50-2:50 pm. LPM and LPA's toured the facility with DDS and TCRC.

Citations issued, exit interview, copy of report, appeal rights were printed and emailed.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 01/08/2024 02:50 PM - It Cannot Be Edited


Created By: Jeannette Olson On 01/08/2024 at 07:46 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: 01/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/10/2024
Section Cited
CCR
80075(b)(5)(B)

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80075(b)(5)(B) Health Related Services. Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:
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Administrator agreed to submit a written plan to CCL addressing all the medication related issued observed/documented in the report and how they will be mitigated in the future by 1/10/24. Administrator also agreed to have medications reviewed weekly and send review to CCL every weeek for
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Based on record review, the licensee did not comply with the section cited above when staff did not follow physician’s orders for medications, which posed an immediate health and safety risk to clientss in care.
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four weeks.
Type B
01/22/2024
Section Cited
CCR80022(k)

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80022(k) The facility shall operate in accordance with the terms specified in the Plan of Operation and may be cited for not doing so.
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Administrator agreed to review the plan of operation with all Staff in Charge (SICs) and submit a plan to CCL on how the facility will implement and follow the plan of operation by 1/22/24
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Based on record review, interview and observation, the licensee did not comply with the section cited above when staff did not follow the plan of operation in several areas, which posed a potential health and safety risk to residents 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:Jeannette Olson
LICENSING EVALUATOR SIGNATURE:
DATE: 01/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2024


LIC809 (FAS) - (06/04)
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