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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425850084
Report Date: 12/20/2023
Date Signed: 12/20/2023 02:14:27 PM

Unsubstantiated


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
05/24/2023 and conducted by Evaluator Jeannette Olson
COMPLAINT CONTROL NUMBER: 29-AS-20230524132546
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:
12/20/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ana Jimenez, Staff in ChargeTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff failed to meet resident’s needs
Staff were not in ratio
Staff violated resident’s visitation rights
Staff mismanaged resident’s medication
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Olson and Miller conducted an unannounced subsequent complaint visit to issue final findings on the allegations 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 Staff in Charge and explained the purpose of the visit.

On the allegations: Staff failed to meet resident’s needs and staff were not in ratio. It was alleged that twice in one month C1 self-harmed and was hospitalized due to staff not preventing C1 from self-harming. It was also alleged that C1 self-harmed, was hospitalized for 10 days and had surgery for a detached retina then a few days later self-harmed again and was hospitalized.
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: 1 of 3
Control Number 29-AS-20230524132546
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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Reporting party states C1 is supposed to have 2 staff present 24/7 and “the incidents occurred due to severe neglect”. LPA reviewed the facility schedule and interviewed 10 staff. Interviews revealed staff are always in ratio since April 2023, and 2 staff were always working with C1 and staff did not work alone. Staff schedules show an open shift in the afternoon on 4/5/23, 4/6/23, 4/11/23 and an open shift in the morning on 4/9/23 and 4/17/23. Staff interviewed stated when there is an open shift or a staff calls out the Staff in Charge (SIC) steps in until a substitute can fill in. Staff also state sometimes the Administrator works a shift and all staff take the ratio seriously to protect C1. All Staff interviewed stated they believe they are properly trained in de-escalation, redirection and restraints to help prevent C1 from harming themselves. Staff implement redirection as soon as possible and restraints as appropriate in the safest way possible to prevent C1 from self-harming. Incident reports and restraint logs show C1 was restrained on 4/16/23, 4/17/23, 4/18/23, 4/20/23, 4/21/23, 4/21/23, 4/22/23, 4/22/23, 4/23/23 and 5/20/23 to help prevent C1 from self-harming. 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. C1 is in the highest level facility licensed by Community Care Licensing. The investigation revealed C1 has a care team of over 10 professionals that meet monthly to ensure C1 is on track and R1’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 is also contacted if any medical issues arise. The nurse communicates with R1’s PCP doctor who sees R1 in-person once a month. Administrator interview revealed that staff training is very comprehensive, and staff constantly monitor R1 to ensure R1’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. Based on the information obtained the allegations Staff failed to meet resident’s needs and staff were not in ratio are deemed Unsubstantiated.

On the allegation: Staff violated resident’s visitation rights. It was alleged that staff isolated C1 from their family while in the hospital and only allowed the family to visit once a day for an hour, violating their personal rights. Client 1 (C1) has a conservatorship where the conservator has full rights over C1 including placement and visitation. The conservator outlined Visitation Guidelines for C1 and has the authority to change and alter it. On 1/27/23 the Limit of Powers of Temporary Conservatorship was petitioned and court and a judge denied the request on 08/11/2023. 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: 3 of 3
Control Number 29-AS-20230524132546
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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It states, “In summary, the evidence supports the Courts’ previous orders authorizing the temporary conservator to limit [C1’s] social and sexual contacts. The evidence further shows the [conservator] has exercised this power reasonably. [Contester] fails to show the [conservator] is abusing its authority by implementing and enforcing the Guidelines, including the Challenged Guidelines.” Staff interviewed indicated they follow the conservator’s guidelines for visitation with C1. Based on the information obtained, the allegation Staff violated resident’s visitation rights is in the hands of the conservator, therefore the allegation is deemed Unsubstantiated.

On the allegation: Staff mismanaged resident’s medication. It was alleged staff are overmedicating C1. LPA interviewed staff, the facility Nurse, and Administrator. Interviews revealed that C1 had just had surgery on 05/09/23 to reattach their retina. C1’s doctor prescribed medication to keep C1 from self harming and possibly dislodging their retina again. LPA reviewed C1’s Medication Administration Record (MAR) and Centrally Stored Medication Log from 4/2/23 to 5/31/23. LPA observed that the medication was given as prescribed per the documentation.
The facility Nurse stated they had a form “24 HR Watch Form” where they would rate C1 using a Richmond Agitation & Sedation Scale (RASS) every 15 minutes to ensure C1 was not over or under medicated. LPA reviewed the RASS forms dated 5/23/23- 5/31/23. All 10 facility staff interviewed stated they didn’t believe C1 was over medicated because staff constantly monitored C1 using this system and also took C1’s Heart Rate and Blood Pressure each shift (every 8 hours). Staff interviewed stated they kept the doctor informed of C1’s status and it would almost be impossible for staff to overmedicate C1 with all the systems and protocols in place. Nurse stated they are an RN and takes their license seriously and would have to report if they thought there was any abuse or mismanagement of medication. Nurse also stated they constantly monitor staff and the medication to ensure it is given properly and per doctor’s orders. If there was anything out of the ordinary RN said they would report it. LPA interviewed C1’s Psychiatrist who stated the Administrator is their main contact and they take C1’s health very seriously. The Doctor stated the Administrator contacts them day or night with any concerns and the Administrator is very cautious and advocates to have C1 conservatively medicated vs “overly medicated.” Based on the information obtained the allegation is deemed Unsubstantiated.

Exit interview conducted, copy of 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)
Page: 2 of 3