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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 421703549
Report Date: 07/15/2021
Date Signed: 07/15/2021 04:30:39 PM

Document Has Been Signed on 07/15/2021 04:30 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 FOUNDATION - WEISMAN CENTER (RCFE)FACILITY NUMBER:
421703549
ADMINISTRATOR:LORETTA CALDERONFACILITY TYPE:
740
ADDRESS:6960 DEVEREUX WAYTELEPHONE:
(805) 968-2525
CITY:GOLETASTATE: CAZIP CODE:
93117
CAPACITY: 15CENSUS: 14DATE:
07/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:48 PM
MET WITH:Nicole Beltran, Program AdministratorTIME COMPLETED:
03:20 PM
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On 7/15/21, at 01:48 PM, Licensing Program Analyst (LPA) Toan Luong conducted an unannounced on-site One Year Infectious Control Annual visit to the facility. LPA met with Program Administrator (PA) Nicole Beltran and Program Director (PD) Jennifer Farley. LPA explained the purpose of the visit.

PA took LPA on a physical plant tour of the facility. The facility has submitted a mitigation plan to the department.

The facility is a Residential Care Facility for the Elderly. During the facility tour, LPA advised posting signs to redirect visitors to the main entrance of the facility. LPA advised PA to have CDSS PINs posted in common hallway and have PINs readily accessible to residents, visitors, and staff. LPA discussed with PA about having staff be fit-tested for N95 respirators.

LPA reviewed the Annual Mitigation Inspection Control Tool Module. Module was addressed with PA to satisfaction.

Exit interview was conducted. No deficiencies were cited. Report was emailed to PD.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE: DATE: 07/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/15/2021
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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