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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 421703549
Report Date: 07/10/2024
Date Signed: 07/11/2024 08:37:57 AM

Document Has Been Signed on 07/11/2024 08:37 AM - 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 FOUNDATION - WEISMAN CENTER (RCFE)FACILITY NUMBER:
421703549
ADMINISTRATOR/
DIRECTOR:		ENEDILIA AVILAFACILITY TYPE:
740
ADDRESS:6960 DEVEREUX WAYTELEPHONE:
(805) 879-0338
CITY:GOLETASTATE: CAZIP CODE:
93117
CAPACITY: 15CENSUS: 14DATE:
07/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Omar Garcia, Program ManagerTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced Annual required inspection at the facility. Upon arrival, LPA was greeted by Omar Garcia, Program Manager and Monica Gomez, Clinical Case Manager. Jennifer Farley, Program Director was unavailable at the time of the visit. LPA explained the purpose of the visit. There are currently fourteen (14) clients residing in the facility. At the time of arrival, there were fourteen (14) clients present with five (5) staff were on duty.

Entrance interview conducted.
The facility is a one-story home to Clients with intellectual/developmental disabilities, has a fire clearance for 15 non-ambulatory clients and a hospice waiver for 2 clients. Currently, there are no residents on hospice. The facility contracts with Tri-Counties Regional Center.
A tour of the physical environment and accommodations were assessed, and the following was noted: LPA observed the required posting of the complaint poster and Resident’s Rights. LPA inspected the one-story facility for fire safety, personal accommodations, and food service.
The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, doors, floors and floor coverings were checked. The facility was seen to be in good repair inside and outside. LPA observed five (5) fire extinguishers serviced on 4/3/2024, two (2) carbon monoxide detectors in good working order, 27 smoke alarms, and an automatic sprinkler system throughout the building.
The kitchen area was sufficiently stocked with two-day perishables and seven days of non-perishables. Frozen foods are properly wrapped and stored appropriately. LPA observed the kitchen cabinets, refrigerator, stove, and counters are clean.
A weekly meeting is conducted with Staff in Charge (SIC) to discuss clients’ activities and planning for the activities for the upcoming week. Clients participate at will in activities with holiday celebrations, birthdays, self-accomplishment celebrations, weekly acknowledgements, painting projects, Bingo, and greenhouse planting. A plan is in progress for the residents to participate in a day trip to Disneyland which will include groups of five residents in three different sessions.
Please continue to 809-C.Page 2
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE: DATE: 07/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/10/2024
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: DEVEREUX FOUNDATION - WEISMAN CENTER (RCFE)
FACILITY NUMBER: 421703549
VISIT DATE: 07/10/2024
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Clients also participate independently in arts and crafts, excursions to the local eateries, museums, and parks, entertainment places, walks, and places of worship.
Medications and First Aid kits are kept in the locked staff office in a locked medication cart.
Meals are prepared by the facility cook. Staff assists with meal distribution and assisting clients with safety precautions and special diet accommodations. Snacks are available throughout the day. Clients may volunteer to complete chores throughout the facility if desired.
The front entrance consists of an open porch with a bench located near the front door. The facility maintains a comfortable temperature and there are no bodies of water.
The facility has twelve (12) bedrooms. Bedrooms #1, 5, and 9 are shared bedrooms. Bedroom #9 has a private bathroom for the two occupants. Bedrooms #11 and 12 are single rooms with a shared bathroom between the two rooms. Bedrooms #2, 3, 4, 6, 7, 8 and 10 are private bedrooms. There are 5 bathrooms with access from the hallway available to all clients and staff. The bathrooms have secure grab bars.
All staff have been properly associated to the facility.
Record review and interviews conducted revealed facility staff have have not received the yearly 20 hours of training in dementia, postural supports, restricted health conditions, and hospice care.

The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in additional civil penalties.

Exit interview conducted. Due to technical difficulties copy of the report and appeal rights were provided via email.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/11/2024 08:37 AM - It Cannot Be Edited


Created By: Kristin Kontilis On 07/10/2024 at 04:33 PM
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 FOUNDATION - WEISMAN CENTER (RCFE)
FACILITY NUMBER: 421703549

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
1569.625(b)(2)
Type A: 1569.625(b)(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training…and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care... This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in seventeen of the seventeen employee training files reviewed, which poses an immediate health, safety, or personal rights risk to persons in care.
POC Due Date: 07/26/2024
Plan of Correction
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Program Manager agrees to conduct 20 hours of training to all staff including but not limited to dementia, postural supports, restricted health conditions, and hospice care. Training to include first and last names of all trainees, description of trainings, outside agency training vendor within due date of POC (7/26/2024).
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:
DATE: 07/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2024


LIC809 (FAS) - (06/04)
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