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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 421703549
Report Date: 02/13/2024
Date Signed: 03/05/2024 08:18:35 AM

Document Has Been Signed on 03/05/2024 08:18 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:ENEDILIA AVILAFACILITY TYPE:
740
ADDRESS:6960 DEVEREUX WAYTELEPHONE:
(805) 879-0338
CITY:GOLETASTATE: CAZIP CODE:
93117
CAPACITY: 15CENSUS: 15DATE:
02/13/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Omar Garcia, Program AdministratorTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced Case Management – Incident visit to the facility. LPA met with Omar Garcia, Program Administrator.
The purpose of today’s visit is to address eight (8) self-reported incidents reported to CCL on 5/18/2023, 5/19/2023, 6/21/2023, 8/7/2023, and 2/5/2024.

Incident #1: On 5/18/2023, CCL received an incident report stating on 5/14/2023, Resident 1 (R1) was not administered a prescribed dosage of SM Enema (suppository) 3x week due to no staff nurse being on duty to administer the dosage. Due to the dosage being a suppository, the enema must be administered by a nurse.


Incident #2: On 5/19/2023, CCL received a revised incident report stating on 5/15/2023, it was discovered that on 5/14/2023 at 8:00 AM, Staff 1 (S1) administered Vitamin B-12 to Resident 2 (R2) in error. LPA obtained a copy of the Physician’s medication order which states, “Take one tablet by mouth every other day.” The vitamin was not to be administered on this day (5/14/2023), as it was an "off" day for the medication.
During today’s visit, Program Administrator Omar Garcia stated S2 was responsible for the medication error. LPA obtained a copy of R2’s Medication Administration Record (MAR) which indicates R2 received one tablet of Vitamin B-12 on 5/13/2023, 5/14/2023, and 5/15/2023.
Incident #3: On 6/21/2023, CCL received an incident report stating on 6/19/2023, Resident 3 (R3) was not administered Lisinopril 40mg at 8:00 am on 6/19/2023 due to the medication had not been refilled. During today’s visit, Program Administrator Garcia stated the procedure to refill medications has been revised and is done weekly for the upcoming week. Program Administrator further stated an inventory is conducted once a week to include expired medications, low inventory medications, and prescription refills.
Incident #4: On 8/7/2023, CCL received three incident reports stating on 8/4/2023 Staff 3 (S3) failed to administer medications to three clients. Resident 4 (R4) was not administered Lacosamide 200mg @ 8:00 am. Resident 5 (R5) was not administered Lorazepam 1mg (1 tab) @ 8:00 am and 1 mg (2 tabs) at
Please continue to 809-C, Pg 2.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2024
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: 02/13/2024
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12:00 noon. Resident 6 (R6) was not administered CBD 20/mg/THC @ 8:00 am. LPA reviewed incident report which stated S3 did not follow facility protocol of having second medication check and stated not administering the medications as prescribed was "an over-sight".
Incident #5: On 2/5/2024, CCLD received two incident reports stating on 2/1/2024 Staff 4 (S4) left their shift early without notice to other staff on duty. S4 was assigned to pass 8:00 pm meds but left it to Staff 5 (S5) to pass out the medications. Incident report states S5 was confused on whether Resident 6 (R6) and Resident 7 (R7) received their meds as the bubble packs were not labeled with dates.
Incident report states the following day, S5 realized the 8:00 pm Atrovastatin 20mg was not passed to R6 and R7. Incident report states S5 notified Staff 6 (S6) who instructed S5 to continue dose as prescribed.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were cited during the visit. (See 809-D) Exit Interview Conducted. A copy of this report, Appeal Rights, and Civil Penalty issued at the time of the visit.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024
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Document Has Been Signed on 03/05/2024 08:18 AM - It Cannot Be Edited


Created By: Kristin Kontilis On 02/13/2024 at 01:01 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: 02/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/15/2024
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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Program Administrator agrees to schedule medication training for all staff by POC due date.
Program Administrator agrees to conduct medication training from an outside source for all staff. Proof of training will include first and last name of trainees, name of trainer
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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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description of training. Training sign-in sheet to be provided to LPA via email.

CIVIL PENALTTY ASSESSED

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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: 02/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024


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