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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850084
Report Date: 03/05/2024
Date Signed: 03/05/2024 02:47:42 PM

Document Has Been Signed on 03/05/2024 02:47 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
WOODLAND HILLS N.ASC, 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: DATE:
03/05/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Chris Patton, AdministratorTIME COMPLETED:
02:56 PM
NARRATIVE
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Licensing Program Analyst (LPA) Erika Miller and Licensing Program Manager (LPM) Kelly Burley conducted a Case Management - Incident visit to the facility above. LPA met with Administrator, Chris Patton and explained the purpose of the visit. LPA was also accompanied by Quality Assurance Specialists (QAS) Vincent Figueroa and Stephanie Cole from Tri-Counties Regional Center (TCRC).

LPA reviewed the Debrief the facility submitted following an incident that occurred on 2/14/2024 to 2/15/2024. The Debrief was also reviewed in consultation with Department of Developmental Services and TCRC. The Debrief indicates multiple unapproved restraints performed by staff on Client 3 (C3), and staff restricted C3’s movement around the facility, including blocking C3 from exiting.

Staff 1 used an unauthorized restraint, placing their arms under C3’s armpits which limited C3’s mobility. Staff 2 placed their foot in front of the front door to prevent C3 opening the door and exiting the facility. C3 pushed through staff and entered Client 2’s room. Client 2 woke up and screamed “no” while crying. Staff attempted to redirect C3 out of the room but were unsuccessful. Staff then carried C3 out of the other client’s bedroom, which was an unapproved restraint. C3 attempted to go into the sensory room, which is used to help clients deescalate and calm down, but staff prevented C3 from going in the room, as they were concerned C3 may leave out the back door in the room. C3 went into the bathroom, stood on the toilet, and tried to crawl out the window. Multiple staff grabbed C3’s legs and pulled C3 out of the window and onto the floor.

LPA reviewed a staff schedule against the incident report and debrief. LPA observed that during the incident, the facility was out of staff to client ratio. The facility should have had 5 staff working for the 3 clients when the incident occurred, but only had 4.

(Continued on 809-C)
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Erika Miller
LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2024
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: DEVEREUX CALIFORNIA - TULAROSA
FACILITY NUMBER: 425850084
VISIT DATE: 03/05/2024
NARRATIVE
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LPA observed that the incident occurred on the overnight shift of 2/14/2024 to 2/15/2024, with the first restraint occurring at 12:15am on 2/15/2024. However, the first debrief did not occurred until 2/17/2024. This is outside of the required 24-hour debrief window.

LPA confirmed that 3 staff have not fulfilled all 16 hours of emergency intervention training. This was previously cited on 2/12/24.

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


An exit interview was conducted, a copy of the report, civil penalty and appeal rights were issued.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Erika Miller
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 03/05/2024 02:47 PM - It Cannot Be Edited


Created By: Erika Miller On 03/05/2024 at 09:23 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: 03/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/06/2024
Section Cited
CCR
85100(b)

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85100(b) General Provisions. When a client's behavior presents an imminent danger of serious injury to self or others, the licensee shall use a continuum of interventions starting with the least restrictive intervention. More restrictive interventions may be used only when less restrictive interventions are determined to be ineffective. This requirement is not met as evidenced by:
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Administrator agreed to have all staff who worked during the incident retrained on restraints. Administrator will send proof training is scheduled by 3/6/2024 and will send proof of completion by 3/12/2024.
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Based on record review, the licensee did not comply with the section cited above when staff performed unauthorized restraints and blocked C3 from exiting, which posed an immediate safety and personal rights risk to clients in care.
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Type A
03/06/2024
Section Cited
CCR85065.5(a)(1)

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85065.5(a)(1) Day Staff-Client Ratio (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. This requirement is not met as evidenced by:
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Administrator agreed to submit a staffing schedule showing adequate staffing coverage required ratios by 3/6/2024
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Based on record review, the licensee did not comply with the section cited above then the facility was not in ratio, which posed an immediate 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:Erika Miller
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 03/05/2024 02:47 PM - It Cannot Be Edited


Created By: Erika Miller On 03/05/2024 at 09:29 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: 03/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/06/2024
Section Cited
CCR
85168.3(a)

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85168.3(a) Manual Restraint or Seclusion Review. The Licensee shall ensure that a debriefing occurs in accordance with Section 1180.5(b) of the Health and Safety Code. This requirement was not met as evidenced by:
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Administrator agreed to submit a written statement of understanding and acknowledgement of 85168.3 and will submit to CCL by 3/6/2024.
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Based on record review, the licensee did not comply with the section cited above when the debrief occurred later than 24 hours after the incident, which posed a potential health, safety, and personal rights risk to clients in care.

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Type B
03/12/2024
Section Cited
CCR85165

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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 Training by 3/19/24
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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:Erika Miller
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2024


LIC809 (FAS) - (06/04)
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