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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 421703549
Report Date: 05/23/2025
Date Signed: 05/23/2025 12:51:58 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/02/2025 and conducted by Evaluator Kristin Kontilis
COMPLAINT CONTROL NUMBER: 29-AS-20250102094412
FACILITY NAME:DEVEREUX FOUNDATION - WEISMAN CENTER (RCFE)FACILITY NUMBER:
421703549
ADMINISTRATOR:OMAR GARCIAFACILITY TYPE:
740
ADDRESS:6960 DEVEREUX WAYTELEPHONE:
(805) 879-0338
CITY:GOLETASTATE: CAZIP CODE:
93117
CAPACITY:15CENSUS: 15DATE:
05/23/2025
UNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Antonela Milito, Program ManagerTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff did not provide responsible party with resident's records.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kristin Kontilis conducted a subsequent complaint visit to issue final findings on this investigation. LPA met with Antonela Milito, Interim 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. During the investigation, LPA conducted an initial visit on 1/8/2025 from 11:00 am to 2:00 pm, where LPA conducted interviews with staff and obtained relevant documents. Additional staff interviews were conducted by phone on 5/15/2025 at 2:14 pm. LPA also interviewed Resident 1's (R1's) responsible party (RP) during the investigation.
On the allegation: Staff did not provide responsible party with resident's records. It was alleged a responsible party was not provided with a resident’s records.
Based on interviews and record review, in October 2024, R1 was diagnosed with stage 3 pressure injuries to the right toe and right ankle. The facility submitted an exception request on 10/22/2024 via fax.

Please continue to 9099-C, Pg 2.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 29-AS-20250102094412
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/23/2025
NARRATIVE
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CCL contacted Program Manager Omar Garcia to request additional documents needed to process the exception request. The exception request was approved by CCL on 12/4/2024, and the facility was notified the same day and provided a copy of the letter.
R1’s RP stated on 11/26/2024 they sent a text message to the Program Manager requesting the records. LPA reviewed a screenshot of the text message, which asked for “a copy of the exception request that you sent to CCLD regarding [R1’s] wound care.” In the interview, R1’s RP stated the information they wanted was what steps the staff were going to take to make sure the wound was going to be taken care of properly. Program Manager confirmed they told RP they could not provide a copy of the exception request, due to confidentiality. Program Manager stated they did not receive a response from R1’s RP.
Program Director stated R1’s RP was aware Program Manager Omar Garcia would no longer be the point of contact in December 2024, as they were on vacation and then would be transferring to a different position at a different facility. However, on 12/2/2024, RP contacted now former Program Manager Garcia, to request the records provided to CCL. Program Director stated they received guidance from upper management that the facility would not provide those documents to responsible parties, but they may be able to request them from CCL. Program Director later stated R1’s RP was directed to get the documents directly from CCL, as Devereux doesn’t usually provide documents regarding an internal process. Program Director stated they had previously provided R1’s RP with specifically requested documents from R1’s file.
Program Director stated no other requests were made to the facility directly, but instead R1’s Regional Center Service Coordinator forwarded the RP’s request on 12/31/2024. Program Director stated the original request sent on 12/2/2024 had been responded to, so there were no direct communications or requests unanswered. RP confirmed they requested the exception request information through the Service Coordinator and attempted to get the documentation from CCL via phone calls and in-person office visits. CCL representative explained to RP confidential information could not be released through CCL.
The initial request for the records was on 11/26/2024, and the exception was not yet approved by CCL. However, the exception request and approval (once received) should have been kept in R1’s resident file. R1’s responsible party, who was also R1’s Power of Attorney (POA), was entitled to all records pertaining to R1, and the facility should have provided the requested records. Based on the information obtained, the allegation is deemed Substantiated at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D):

Exit interview conducted. Copy of report and Appeal Rights issued at the time of the visit.

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

DATE: 05/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20250102094412
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/28/2025
Section Cited
CCR
87506(c)(1)
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87506(c)(1) Resident Records…The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative.
This requirement was not met as evidenced by:
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Program Manager agrees to provid a resident's records upon request to residents' responsible parties. Program Manager agrees to provide written statement to CCLD acknowledging CCR87506. Administrator agrees to submit written statement directly to LPA via email no later than POC due date.
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Based on interview and record review, the licensee did not comply with the section cited above when R1’s RP was not provided records, which posed a potential health, safety and personal rights 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.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3