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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850084
Report Date: 07/18/2022
Date Signed: 07/18/2022 04:24:42 PM


Document Has Been Signed on 07/18/2022 04:24 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
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: 1DATE:
07/18/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Chris Patton, AdministratorTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Olson conducted an unannounced on-site visit to the facility in regards to an incident reports for medication errors received from the facility. LPA met with Administrator Chris Patton and explained the purpose of the visit.

Incident reports stated the following:

On 6/8/22, at 7:30pm, staff discovered Client 1 (C1) did not receive their noon dose of Pregabalin 100mg. Staff called C1's doctor who instructed to skip the dose and continue with the next scheduled dose at 8pm. The incident report states Staff 1 (S1) failed to provide C1 the dose.

On 7/13/22 at 7:15 pm, staff discovered 1 pill of Benztropine MES 1mg remained in bubble pack for 7/12/22 8:00 p.m. dosage for C1. Staff 2 (S2) stated the bubble pack was popped but the pill remained in the bubble pack and did not drop into the container. Staff 3 (S3) conducted a double-check of the medications and failed to notice the medication remained in the bubble pack.

Exit interview conducted with Administrator, deficiencies cited on 809-D, civil penalty assessed for repeat violation, report and appeal rights emailed to the Administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2022
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 07/18/2022 04:24 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/19/2022
Section Cited

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80075 Health Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement was not met as evidence by:
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Based on interview and incident reports, the licensee did not comply with the section above as multiple incident reports were submitted which poses an immediate health, safety, or personal rights risk to persons 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 BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2022
LIC809 (FAS) - (06/04)
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