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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850084
Report Date: 02/12/2024
Date Signed: 02/12/2024 11:11:12 AM

Document Has Been Signed on 02/12/2024 11:11 AM - 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:
02/12/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Chris Patton, AdministratorTIME COMPLETED:
11:25 AM
NARRATIVE
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Licensing Program Analyst (LPA) Jenny Olson a conducted a Case Management - Deficiencies visit to the facility above. LPA met with Administrator, Chris Patton and explained the purpose of the visit. These deficiencies were observed by Department of Developmental Services and CCL during a semiannual visit conducted 1/17/2024, and by Tri-Counties Regional Center staff on visits on 1/7/2024, 1/9/2024, and 1/10/2024.

It was observed that the facility did not have adequate staffing and was not in ratio on multiple shifts. Based on a staffing review, multiple open shifts were observed 7/30/23-8/5/23, 8/13/23-8/19/23, 9/17/23-9/23/23, 10/1/23-10/7/23, 11/12/23-11/18/23. Additionally, the facility was out of ratio on 1/7/24, 1/9/24, and 1/10/24.

It was observed that Staff 1 (S1) did not have first aid training completed. It was also observed that 6 staff had less than the required 16 hours of emergency intervention training, and some of those staff had participated in restraints without proper training.

It was observed that multiple lead staff did not meet the requirements of lead staff per the program plan, which include obtaining a Registered Behavior Technician certification within 2 months of employment, or if they are a Licensed Psychiatric Technician or Qualified Behavior Modification Professional.

It was observed that two out of the three clients did not have an Individual Program Plan (IPP) on file as required per the program plan.

It was observed that although staff had completed DSP 1 and 2 training as required, they were completed outside of the required timeframe.
Continued on 809-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE: DATE: 02/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/12/2024
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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Document Has Been Signed on 02/12/2024 11:11 AM - It Cannot Be Edited


Created By: Jeannette Olson On 02/12/2024 at 07:44 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: 02/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/13/2024
Section Cited
CCR
85065.5(a)(1)

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85065.5 Day Staff-Client Raton(a)...the following minimum staffing requirements shall be met: (1) For Regional Center clients, staffing shall be maintained as specified by the Regional Center but no less than one direct care staff to three such clients.
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Licensee shall submit a staffing schedule with adequate staffing coverage per TCRC ratio's by 02/13/2024.
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This requirement is not met as evidenced by: Based on record review, the facility did not follow prescribed staff to client ratios on numerous occasions, which posed an immediate health and safety risk to clients in care.
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Type B
02/19/2024
Section Cited
CCR85165(b)

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85165(b) Emergency Intervention Staff Training (b) Staff who use, participate in, approve or provide visual checks of manual restraint or seclusion, shall have a minimum of sixteen hours of emergency intervention training and be certified for having successfully completed the training.
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Administrator agreed to submit proof that all staff have completed their 16 hours of Emergency Intervention Trainging by 2/19/24
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This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above when staff did not have the16 hours of emergency intervention training, which posed a potential health and safety risk to clientss 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: 02/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2024


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: 02/12/2024
NARRATIVE
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Technical Assistance is issued and CCL recommends an improved training schedule to track staff’s due dates and completions of required trainings. It was also observed during visits in January 2024 that while clients were in there rooms or asleep, staff were unaware of the protocol to check on clients. Technical Assistance is issued and CCL recommends retraining all staff on the protocol to check on clients, and/or issue a written procedure for staff to follow. It was also observed that the facility’s files lacked clear organization, and it was suggested to create files/binders that house all documents required by DDS/TCRC/CCL to streamline file reviews.

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

A civil penalties for a repeat violation for $250 was assessed.

An exit interview was conducted, a copy of the report, Civil Penalty, and appeal rights were issued.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 02/12/2024 11:11 AM - It Cannot Be Edited


Created By: Jeannette Olson On 02/12/2024 at 08:35 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: 02/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/12/2024
Section Cited
CCR
89965(k)(1)

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89965 Personnel Requirements (k) ...each direct care staff person receive hands-on training in first aid and cardiopulmonary resuscitation. (1) Direct care staff shall maintain current certifications in first aid and cardiopulmonary resuscitation.... This requirment was not met as evidenced by:
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Administrator submitted proof staff 1 was trained in first aid. POC cleared during the visit.
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Based on record review, the licensee did not comply with the section cited above when one staff was not current on CPR/First Aid, which posed a potential health and safety risk to clients in care.
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Type B
02/19/2024
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 submit a plan to CCL on how the facility will implement and follow the plan of operation in reguards to training by 2/19/24.
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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 clients 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: 02/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2024


LIC809 (FAS) - (06/04)
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