425850084-12-20-2023-29-AS-KBUY-CYQUL2-20231221144002

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425850084
Report Date: 12/20/2023
Date Signed: 12/20/2023 02:40:03 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/09/2023 and conducted by Evaluator Jeannette Olson

COMPLAINT CONTROL NUMBER: 29-AS-20230509112410

FACILITY NAME:	DEVEREUX CALIFORNIA - TULAROSA		FACILITY NUMBER:	425850084
ADMINISTRATOR:	PATTON, CHRISTOPHER		FACILITY TYPE:	737
ADDRESS:	1855 TULAROSA ROAD		TELEPHONE:	(805) 879-0357
CITY:	LOMPOC	STATE: CA	ZIP CODE:	93436
CAPACITY:	3	CENSUS: 3	DATE:	12/20/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Chris Patton, Administrator		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Facility staff did not seek client timely medical attention.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA's) Olson and Miller conducted an unannounced subsequent complaint visit to issue final findings on the allegation above. LPA Olson collaborated with Tri-Counties Regional Center Quality Assurance Specialist (QAS) Vincent Figueroa on the investigation and interviewed staff on 5/22/23 at 11:30am, 1:15pm, and 3:15pm; 6/1/23 at 10:16am, 11:45am, and 12:19pm; 8/30/23 at 11am, 11:46am, and 12:12pm; 9/15/23 at 2:40pm and 3:08pm; 9/26/23 at 2:41pm and 3:25pm; Administrator on 5/11/23 at 1:05pm, 5/19/23 at 11am, 5/31/21 at 8:08am, 6/1/23 at 9:50am, 9/15/23 at 3:30pm; Cal Retina on 8/15/23 at 12:32 and 10/4/23 at 12:21pm . LPA met with Administrator and explained the purpose of the visit.

On the allegation: Facility staff did not seek client timely medical attention. It was alleged that on or around 4/22/2023 Client 1 (C1) got a black eye and was complaining of blurry vision and staff did not seek medical attention for C1 in a timely manner.
Continued on 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 7

Control Number 29-AS-20230509112410

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/20/2023

NARRATIVE

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LPA interviewed 10 staff and reviewed C1’s documents including physician’s report, care plan, Body Check forms from 4/17/23-5/5/23 where injuries are recorded and ABC data Collection sheets from 4/8/23-4/30/23 where comments and notes are recorded, and Skill Acquisition Logs from 4/1/23-4/30/34. C1 is in the highest level behavioral facility licensed by Community Care Licensing. C1 has a conservator and is a Tri-Counties Regional Center client. C1’s diagnoses include developmental disability, autism spectrum disorder, and C1 frequently exhibits property destruction and Self-Injurious Behavior (SIB), which was noted to have improved since moving into the facility. The investigation revealed C1 has a care team of over 10 professionals that meet monthly to ensure C1 is on track and C1’s goals and needs are being met. The care team includes a Board Certified Behavior Analyst (BCBA), a Quality Behavior Modification Professional (QBMP), Assistant Supervisor, Program Administrator, and a Program Coordinator. C1’s nurse is present at the facility every week for 10 hours, and should be contacted if any medical issues arise. The nurse communicates with C1’s PCP doctor who sees C1 in-person once a month. Administrator interview revealed that staff training is very comprehensive, and staff constantly monitor C1 to ensure C1’s care plan is being followed. This care plan helps ensure C1 is meeting monthly goals and all of C1’s needs are being met.

On 4/22/23, Body check documents revealed that C1 had Self Injurious Behavior level 2 (SIB2) to the left eye which resulted in eye redness and eye swelling. On 4/23/23, Body check documents revealed that C1 had SIB3 to the left eye with eye redness and swelling.
One staff stated that on Sunday, 4/23/23, C1 was having a hard day and kept hitting/punching their eye. The staff indicated they followed C1’s behavior plan and tried breathing and counting exercises with C1, but ultimately implemented a one-person restraint for less than 30 seconds to try to deescalate C1 and try to prevent SIB (Self-Injurious Behavior) to the eye. Staff indicated C1 dug their nails into the staff’s arm during the restraint and the staff’s arms were “dripping blood” after. Staff indicated C1 had punched their eye a few times during the behavioral incident that day, but C1 did not indicate any issues with their eye or pain. On 4/25/23, the body check states there was SIB3 to the eye on 4/23/23, and observed on 4/25/23 “L Eye swelling & bruise.” C1’s records indicate they have a long history of SIB to the eye area, and all staff interviewed indicated redness and swelling after SIB was normal and did not require emergent medical attention based on past experiences. Staff interviewed stated they first heard C1 say “blurry eyes” on 4/25/23.

Continued on 9099-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

LIC9099 (FAS) - (06/04)

Page: 6 of 7

Control Number 29-AS-20230509112410

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/20/2023

NARRATIVE

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Data Collection Sheet on 4/26/23 indicates C1 stated “eye hurts” around 5pm and notes indicate C1 had verbal perseveration and repeated the phrase. Interviews with staff revealed C1 will regularly say their whole body hurts or certain areas hurt after SIB and “be nice to (body part)” several times per day. Staff present that day stated they didn’t think much of it because there were no behaviors (SIB, Aggression, or Property Destruction) which usually means something is bothering C1. Staff stated if it would have become a behavior they would have told the administrator or nurse. Staff stated when C1 states something hurts they ask questions about what hurts and why. If C1 just repeats themselves (verbal perseveration as indicated on the Data Collection Sheet) then they mark it as such. If C1 describes the pain or something more specific staff state they call the Administrator or nurse for a PRN. On 4/26/23, C1 perseverated on “eye hurts” but did not respond to staff follow up questions about what hurt and why. Skill Acquisition paperwork stated on 4/27/23 C1 said “eye doctor” at 8:15am, 8:45am, 9:14am and 9:15am. One staff interviewed stated they first heard C1 say “blurry eyes” on 4/27/23 at 12:30pm. Another staff interviewed stated they first heard C1 say “blurry eyes” on 4/27/23 before C1 went to the ER. C1 went to the ER around 2:15pm on 4/27/23 to be seen for a possible infection from a previous self-bite to the arm. At the ER staff stated C1 did not mention blurry eyes to the doctor or staff. Administrator and all staff stated they didn’t mention it to the doctor after the doctor asked C1 if anything else was bothering them, because C1 can communicate to the doctor if something is bothering C1, using short sentences and phrases.

Data Collection Sheet on 4/28/23 around 6am “eyes are blurry” is stated under notes. Staff interviewed stated C1 had a previous behavior where C1 said “eyes are weird” or “eyes are blurry”, and then ran into a wall, so staff thought this phrase was a recurring behavior for C1. On 4/28/23 at 2:40pm C1 mentioned blurry eyes to family members and staff. Administrator stated they called C1’s Psychiatrist at 2:45pm to check if any of C1’s medications may be resulting in their blurry vision and called CAL Retina at 3:30pm to set up an appointment. Administrator called CAL Retina again on Monday 5/1/23 and got an appointment for C1 on 5/3/23. On 5/3/23 during the visit, the doctor stated C1 had a detached retina and should get into surgery no later than 5/8/23. C1 had surgery to reattach their retina on 5/6/23 at University of California Irvine Medical Center. Staff interviews indicated C1 typically had red or swollen eyes, and C1 does perseverate on words, but does not say “eye hurts” that often, but around once or twice a week. The staff stated C1 increased perseveration and stated “can’t see” and “eyes blurry” every day until C1 saw the doctor. LPA Interviewed C1’s Psychiatrist on 10/11/23 and 10/13/23 who stated Administrator frequently calls/texts concerns about C1. Psychiatrist stated they had notes stating Administrator called on 4/28/23 because C1 was complaining about blurry vision and Administrator wanted to ensure C1’s meds weren’t causing it. Continued on 9099-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

LIC9099 (FAS) - (06/04)

Page: 7 of 7

Control Number 29-AS-20230509112410

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/20/2023

NARRATIVE

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Psychiatrist ordered blood work that was completed on 5/1/23 and C1’s blood was at normal levels. LPA interviewed a manager at CAL Retina on 8/15/23 at 12:32pm who confirmed that the Administrator called on 4/28/23 and 5/1/23, and explained C1’s symptoms. The manager called the doctor on 5/1/23 and relayed C1’s symptoms, and the doctor said it was “non-urgent” and said it could wait until the next available appointment on 05/03/23.

LPA interviewed C1’s eye doctor on 10/4/23 at 12:21pm. The doctor stated that a person would not show any signs/symptoms of a detached retina, and there would be no external signs like redness or pain. The doctor explained there are two types of retina detachment, “Retina On” and “Retina Off”. “Retina On” is when a part of the retina starts detaching and the only sign is loss of vision in the periphery, flashing lights and floaters. The doctor stated from their experience C1 would not be able to convey and communicate the detailed symptoms such as loss of peripheral vision, flashing lights and floaters. The doctor stated C1 did convey general pain and discomfort with redness or swelling, which could potentially just indicate discomfort/irritation. The doctor stated Retina On is something that needs to be treated immediately withing 24-48 hours to prevent “Retina Off”. The Doctor stated C1 stated blurry vision and that means C1 had a “Retina Off” and there is no rush to reattach it. The doctor stated they would have even waited longer to reattach it. C1’s doctor feels the staff did all they could to help C1, as they went to the ER on 4/28/23, and based on the symptoms communicated, the doctor would not have seen C1 sooner as it seemed nonurgent.

As part of C1’s care plan, staff will restrain C1 when C1 exhibited extreme SIB if other de-escalation techniques are not effective. Incident reports for restraints state the restraints were performed “Because (C1) has self-inflicted blindness in (their) right eye due to history of extreme SIB prior to Devereux care, and as (C1’s) SIB behavior continued to pose an imminent risk to (C1’s) left Eye.” The investigation revealed all staff were well aware that C1 had prior eye issues due to extreme SIB, and most of C1’s care plan is geared toward keeping their eyes protected. The facility staff did not contact the facility nurse per protocol after C1 expressed issues with their eyes, and did not seek other medical attention for C1 until 3 days after they first indicated “blurry eyes” and 2 days after they first indicted “eyes hurt.” Based on the information obtained, the allegation is deemed Substantiated.

Exit interview completed, copy of report and appeal rights issued.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 7

Control Number 29-AS-20230509112410

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/20/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/21/2023 Section Cited CCR 85075(b)	1 2 3 4 5 6 7	85075 Health-Related Services (b) The facility shall develop and implement a plan which ensures that assistance is provided to the clients in meeting their medical and dental needs. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator agreed to submit a written plan to ensure client’s complaints of a medical nature are addressed timely, and will submit the plan by 12/21/23. Administrator agreed to train all staff on the new plan by 12/27/23.
	8 9 10 11 12 13 14	Based on interviews and record review, the Licensee did not comply with the section cited above when Staff did not follow their plan of operation or seek timely medical care by contacting a medical professional when C1 stated “eyes hurt” and “eyes blurry”, which	8 9 10 11 12 13 14	posed an immediate health and safety risk to client in care.
	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.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 7

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/09/2023 and conducted by Evaluator Jeannette Olson

COMPLAINT CONTROL NUMBER: 29-AS-20230509112410

FACILITY NAME:	DEVEREUX CALIFORNIA - TULAROSA		FACILITY NUMBER:	425850084
ADMINISTRATOR:	PATTON, CHRISTOPHER		FACILITY TYPE:	737
ADDRESS:	1855 TULAROSA ROAD		TELEPHONE:	(805) 879-0357
CITY:	LOMPOC	STATE: CA	ZIP CODE:	93436
CAPACITY:	3	CENSUS: 3	DATE:	12/20/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Chris Patton, Administrator		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Facility staff did not meet client's needs.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA's) Olson and Miller conducted an unannounced subsequent complaint visit to issue final findings on the allegation above. LPA Olson collaborated with Tri-Counties Regional Center Quality Assurance Specialist (QAS) Vincent Figueroa on the investigation and interviewed staff on 5/22/23 at 11:30am, 1:15pm, and 3:15pm; 6/1/23 at 10:16am, 11:45am, and 12:19pm; 8/30/23 at 11am, 11:46am, and 12:12pm; 9/15/23 at 2:40pm and 3:08pm; 9/26/23 at 2:41pm and 3:25pm; Administrator on 5/11/23 at 1:05pm, 5/19/23 at 11am, 5/31/21 at 8:08am, 6/1/23 at 9:50am, 9/15/23 at 3:30pm; Cal Retina on 8/15/23 at 12:32 and 10/4/23 at 12:21pm . LPAs met with Administrator and explained the purpose of the visit.

On the allegation: Facility staff did not meet client's needs. It was alleged that the reporting party “observe[d] poor hygiene, emotional and medical neglect”. Complaint Intake Analyst (IA) and LPA Olson requested more information from the complainant. LPA and IA did not receive a response from complainant on details regarding poor hygiene and “emotional and medical neglect”. Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 7

Control Number 29-AS-20230509112410

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/20/2023

NARRATIVE

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LPA interviewed the staff who worked with C1 leading up to the eye surgery as well as the staff who accompanied C1 to the surgery in Irvine. Interviews revealed C1 prefers to wear their pajamas and showers daily. Staff stated that to get to the surgery on time, they had to wake C1 up on 5/6/23 at 2am and C1 was very tired and did not want to change out of their pajamas, but had showered the night before. Based on C1’s care plan and staff interviews, C1 is able to handle their personal hygiene independently. LPA Olson observed C1 on 4/13/23, 5/16/23, 6/1/23, 7/10/23, 8/10/23, 8/30/23, and 9/15/23 and 12/20/23 and did not observe poor hygiene for C1.

LPA observed visit logs for C1’s medical, dental, vision, and psychiatrist appointments. C1 appears to be regularly seen by medical professionals. C1 sees their Psychiatrist and Primary Care Physician Monthly, Staff met with a dietitian regarding C1 on 3/27/23, 5/18/23, and 5/19/23, C1 saw the Gastroenterologist on 8/29/23, and received a dental cleaning on 9/28/23. Administrator stated in interview they personally schedule all of C1’s appointments and ensure they are attended or rescheduled as appropriate. Administrator stated they are also responsible for scheduling follow-up appointment per the medical professional’s orders. Based on the information obtained, the allegation does not have enough information to investigate, therefore it is Unsubstantiated at this time.

Exit interview conducted, copy of the report issued.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

LIC9099 (FAS) - (06/04)

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