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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425850084
Report Date: 05/30/2024
Date Signed: 05/30/2024 09:22:22 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
04/03/2024 and conducted by Evaluator Erika Miller
COMPLAINT CONTROL NUMBER: 29-AS-20240403154128
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:
05/30/2024
UNANNOUNCEDTIME BEGAN:
08:43 AM
MET WITH:Ana Jimenez, TIME COMPLETED:
09:24 AM
ALLEGATION(S):
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Staff are not giving residents medication as prescribed

Staff are out of ratio
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Erika Miller (Miller) conducted an unannounced complaint visit on April 11, 2024. On May 30, 2024 LPA Miller issued final findings on the allegations above. During the investigation, LPA, Miller, toured the facility and interviewed Administrator and staff on April 11, 2024 from 10:30 a.m. to 12:30 p.m. LPA also obtained and reviewed relevant documents.

Three of three staff stated that they have not observed any instances of overmedicating residents in care. Staff stated that they use the Seven Rights of Medication Administration to ensure that they administer proper medication dosages. Staff stated they are trainedn administering medication upon hire and get training annually. Staff further stated that they follow prescription and match medication to the Medication Administration Record (MAR) to ensure safety protocols. There is a system in place that uses timing alarms to remind staff to administer prescriptions and send a photo of medication to Administrator.
Continuned on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Erika Miller
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024
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 6
Control Number 29-AS-20240403154128
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/30/2024
NARRATIVE
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The facility uses a newly implemented plan that uses a color-coded system to identify the time medication is administered. A “second check” audit is completed by staff within the medication window to ensure proper procedure was followed. Staff has not observed any residents appear groggy or over-rmedicated.
In the event of a prescription error, (double-dose) facility policy requires that staff notify Administrator or on-call nurses and notify the prescriber. The facility policy also requires that in the event of any med-error they will receive one-on-one training and they are required to complete an incident report and submit to Community Care Licensing.

Administrator stated, “for last three years, there have been no over-medication errors.” Administrator ensures that staff passes medications properly by several methods. Facility uses medication in bubble packs, the MAR, follows prescriptions and consults with physicians, and uses a “second check” audit.

LPA Miller conducted an audit of all April bubble packs for all three residents and observed that prescriptions matched the recorded MAR. There is no evidence of over-medicating residents in care. On May 17, 2024, it was discovered that R1 received 300 MG of Lithium Carbonate, instead of 600 MG on May 15, 2024, and May 16, 2024. R1 was not over-medicated, but R1 was not given medication as prescribed.
Based on LPA’s interviews that were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Erika Miller
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20240403154128
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/31/2024
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 5/31/24. 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 A
05/31/2024
Section Cited
CCR
85065.5(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 5/31//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.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Erika Miller
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 29-AS-20240403154128
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/30/2024
NARRATIVE
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This is an amended report. On May 30, 2024, LPA Miller reviewed staff schedule for the week of May 19, 2024 to May 25, 2024 and observed that 6 unfilled shifts occurred, three were as a result of "call-outs".

Based on LPA’s review of documentation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Exit interview conducted, California Code of Regulations, (Title 22, Division 6 & Chapters 1 and 6), are cited on the attached LIC 9099D) and copy of report issued with appeal rights.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Erika Miller
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
04/03/2024 and conducted by Evaluator Erika Miller
COMPLAINT CONTROL NUMBER: 29-AS-20240403154128

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:
05/30/2024
UNANNOUNCEDTIME BEGAN:
08:43 AM
MET WITH:Ana Jimenez, Assistant AdministratorTIME COMPLETED:
09:24 AM
ALLEGATION(S):
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Staff are isolating residents in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Erika Miller (Miller) conducted an unannounced complaint visit on April 11, 2024. On May 29, 2024 LPA Miller issued final findings on the allegations above. During the investigation, LPA, Miller, toured the facility and interviewed Administrator and staff on April 11, 2024, from 10:30 a.m. to 12:30 p.m. LPA also obtained and reviewed relevant documents.

Three of three staff have never observed any staff isolate residents or discuss isolating residents. Staff are not aware of any policy that permits staff to isolate residents. Staff stated, “residents chose when to go to their room” and are not forced to remain their bedroom. Staff further stated, “ we would not violate human rights.”

A witness, who visits frequently stated that they have never observed or heard of residents being isolated.
(Contiued on 9099-C)

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Erika Miller
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20240403154128
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/30/2024
NARRATIVE
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Administrator stated that residents are not isolated. In fact, Administrator stated that Resident 1(R1) has been attending a day program effective February 12, 2024, Monday through Friday, from 8:00 a.m. to 2:00 p.m. Administrator stated that facility does not use isolation as infringing on personal rights is forbidden.

Based on LPA’s interviews that were conducted and observations made. The allegation is deemed Unsubstantiated at this time. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

Exit interview conducted and copy of report issued.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Erika Miller
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6