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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 421703549
Report Date: 11/17/2022
Date Signed: 11/17/2022 03:11:56 PM

Document Has Been Signed on 11/17/2022 03:11 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:ENEDILIA AVILAFACILITY TYPE:
740
ADDRESS:6960 DEVEREUX WAYTELEPHONE:
(805) 879-0338
CITY:GOLETASTATE: CAZIP CODE:
93117
CAPACITY: 15CENSUS: 15DATE:
11/17/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:46 PM
MET WITH:Omar Garcia, Program Manager; Jennifer Farley, Program DirectorTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Kristin Kontilis conducted a Case Management - Incident visit to issue deficiencies on multiple medication errors the facility has experienced. Due to the situation surrounding COVID-19, CCL was providing technical assistance when some of these incidents occurred. However, during today’s visit the LPA notified the administrator that any future medication errors would result in the issuance of civil penalties for repeat violations occurring within a 12-month time frame.

The facility self-reported medication errors on the following dates: 8/9/2020, 10/18/2020, 11/29/2020, 1/26/2021, 9/28/2022.

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. Citation issued. Copy of report and Appeal Rights issued via email.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2022
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 11/17/2022 03:11 PM - It Cannot Be Edited


Created By: Kristin Kontilis On 11/17/2022 at 11:03 AM
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: 11/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/17/2022
Section Cited
CCR
87465(c)(2)

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87465(c)(2) Incidental Medical and Dental Care. 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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Staff who committed the medication errors received retraining. POC cleared during visit.
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Based on records 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 residents 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 Burley
LICENSING EVALUATOR NAME:Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2022


LIC809 (FAS) - (06/04)
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