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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 421703549
Report Date: 07/26/2022
Date Signed: 07/27/2022 07:57:54 AM

Document Has Been Signed on 07/27/2022 07:57 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:NICOLE BELTRANFACILITY TYPE:
740
ADDRESS:6960 DEVEREUX WAYTELEPHONE:
(805) 879-0338
CITY:GOLETASTATE: CAZIP CODE:
93117
CAPACITY: 15CENSUS: 15DATE:
07/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Leticia Villareal, Quality Management ManagerTIME COMPLETED:
05:30 PM
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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced on-site one-year Infection Control Inspection visit to the above-named facility. LPA arrived at 12:50 pm was greeted by Interim Administrator, Enedelia Avila. Also present during the inspection was Jennifer Farley, Program Director, and Leticia Villareal, Quality Management Manager. At the time of arrival, there were 15 residents in care and 5 staff on duty.
A Mitigation Plan has been submitted to CCLD. LPA explained the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) and is home to non-ambulatory residents with a dementia diagnosis and a hospice waiver for two residents. Currently there are no residents on hospice.
Entrance interview conducted:
The facility has an entry station at the front of the building. Upon entry, staff, visitors, and residents returning from an outing are required to sign-in, complete a symptom questionnaire, and have a temperature screening. All documentation is kept in a binder filed on a weekly basis. The entry station has PPE gear, hand sanitizer, and disinfecting wipes along with a thermometer.
A tour of the physical environment and accommodations were assessed, and the following was noted: LPA observed the required posting of the complaint poster, bill of rights and Resident’s Rights. LPA inspected the one-story facility for fire safety, personal accommodations, and food service. First aid kit was observed to be complete.
The facility has a dining area and common area for activities, a computer room located off the hallway, a exercise room, and an enclosed patio for gardening and visitation. Cleaning supplies are kept in a locked custodian closet.
The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, doors, floors and floor coverings were checked. There are approximately seventeen (17) fire extinguishers on the premises last serviced on 4/20/2022 and 4/21/2022. There are seven (7) fire pull alarms that will alert the l
Please continue to 809-C, Pg 2.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: 07/26/2022
NARRATIVE
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local fire department when activated. There are three (3) dual smoke/carbon monoxide alarms located in the kitchen, laundry room, and in the water heater closet.
There are three (3) shared bedrooms and eight (8) private bedrooms. There are eight (8) bathrooms located throughout the facility; two of the eight bathrooms have two toilet stalls.
Snacks and beverages are available for residents in care upon request. LPA observed the kitchen cabinets, refrigerator, stove, and counters are clean. Medications are kept in a locked centrally stored cabinet in the Medications Services Dept. Sharps are kept in a drawer located in the locked kitchen preparation area.
At approximately 2:21 pm, LPA observed Health Care Staff (HCS1) providing care to Resident 1 (R1) not wearing a mask.
At approximately 2:58 pm, Interviews revealed the facility subcontracts with a home care agency to provide care and supervision staffing to residents in care. LPA reviewed Department of Social Services, Community Care Licensing Division, Licensing Information System (LIS), Facility Personnel Report summary and home care agency’s staff schedule. LPA determined two (2) of the staff from the home care agency currently work in the facility and were not associated to the facility prior to providing staffing assistance. Interim Administrator stated Home Care Staff 1 (HCS1) began working in the facility approximately one year ago and Home Care Staff 2 (HCS2) started working in the facility in 2019.
Upon record review and interviews conducted, LPA determined the facility has not had a certified administrator since on or about October 4, 2021. Jennifer Farley, Program Director, stated on or about 9/10/2021, Administrator Michelle Viernes was designated as Program Administrator, however, Farley further stated Administrator Viernes has not met the qualifications to be designated as Program Administrator. Farley further stated Enedelia Avila, Interim Program Administrator, has accepted the Interim Program Administrator position until certification has been completed for Viernes. Leticia Villareal, Quality Management Manager, stated required documents naming Avila as Interim Program Administrator will be completed and submitted to CCL no later than 8/2/2022.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):


Exit interview conducted. Copy of report and Appeal Rights sent via email.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022
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Document Has Been Signed on 07/27/2022 07:57 AM - It Cannot Be Edited


Created By: Kristin Kontilis On 07/26/2022 at 04:43 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: 07/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(1)
87355(e)(1) Criminal Record Clearance. All individuals…shall prior to working, residing or volunteering in a licensed facility: Obtain a California clearance or a criminal record exemption as required by the Department. This requirement is not met as evidenced by:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not ensure that HCS 2 had a fingerprint clearance prior to working, which posed an immediate health and safety risk to residents in care
POC Due Date: 07/27/2022
Plan of Correction
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Program Director agrees to submit association paperwork for HCS 2 by 7/27/2022. Program Director agrees to not allow staff to work again until associated
Section Cited
Deficient Practice Statement
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87355(e)(2) Criminal Record Clearance. All individuals…shall prior to working, residing or volunteering in a licensed facility: Request a transfer of a criminal record clearance as specified in Section 87355(c)

This requirement is not met as evidenced by:
POC Due Date: 07/27/2022
Plan of Correction
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Program Administrator agrees to submit association paperwork for HCS 1 by 7/27/2022. Program Administrator agrees to not allow staff to work again until associated.
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: 07/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2022


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Document Has Been Signed on 07/27/2022 07:57 AM - It Cannot Be Edited


Created By: Kristin Kontilis On 07/26/2022 at 04:52 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: 07/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.1(a)(2)
Personal Rights of Residents: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with regulation above when HCS 1 was present in the facility without wearing the mask properly, which poses an immediate personal rights risk to residents in care.
POC Due Date: 07/27/2022
Plan of Correction
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Program Administrator agrees to schedule infection control training, including mask requirements, for all staff by 7/27/2022. Training will be completed and provide proof of training with staff signatures by 8/2/2022
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: 07/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2022


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Document Has Been Signed on 07/27/2022 07:57 AM - It Cannot Be Edited


Created By: Kristin Kontilis On 07/26/2022 at 04:56 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: 07/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87405(a)
87405(a) Administrator Qualifications and Duties. All facilities shall have a qualified and currently certified administrator. This requirement is not met as evidenced by:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not ensure the facility currently has a certified Administrator, which poses a potential health and safety risk to residents in care.
POC Due Date: 08/05/2022
Plan of Correction
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Program Administrator agrees to provide all required documents to CCL to designate a qualified/certified Administrator by 8/5/2022.
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: 07/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2022


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