Devereux Foundation - Weisman Center (rcfe)

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced 10-day complaint investigation based on the above stated allegations. Adela Cortinas, Quality Assurance Specialist, Tri-Counties Regional Center accompanied LPA in the visit. LPA met with Monica Gomez, Clinical Case Manager and Sydney Steiner, Program Manager, Weisman Center. Jennifer Farley, Program Director participated in the visit via Teams. During the visit, LPA obtained various documents pertinent to the investigation and conducted interviews from from 11:50 am – 3:30 pm. On the allegation: Staff did not follow reporting requirements: On 11/17/2025, CCLD received an incident report and SOC341 Report of Suspected Dependent Adult/Elder Abuse self-reporting an incident that occurred on 11/14/2025. The report received was in full detail per CCR regulations and therefore, Unsubstnaited at this time. Exit interview conducted. No deficiencies issued. Copy of report issued at the time of the visit. UnsubstantiatedRead the full finding— CDSS inspection report, February 13, 2026 · control 29-AS-20260209115957

At 9:00am on 11/12/2025, Licensing Program Analyst (LPA) Jeffries arrived unannounced to conduct an initial investigation visit pertaining to the allegation listed on this complaint. LPA met with Administrator, Enedilia Avila (S1) and Program Director, interim Program Manager, Sydney Steiner (S2), Case Manager, Monica Gomez (S3), Quality Manager, Eric Christensen (S4), announced who he is and the reason for the visit. LPA conducted interviews with Administrative staff. LPA requested and reviewed documentation. LPA presented a written request for documentation pertaining to Resident 1 (R1) from R1'a responsible party (F1). Facility staff secured R1's facility file and presented documents to LPA. LPA noted that some of the documents requested were visually confirmed to have additional residents names and additional residents information and were not collected to protect the identities of individuals not related to the allegation to this complaint. LPA requested an itemized explanation foRead the full finding— CDSS inspection report, November 12, 2025 · control 29-AS-20251107163849

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 sRead the full finding— CDSS inspection report, May 23, 2025 · control 29-AS-20250102094412

Licensing Program Analyst (LPA) Kristin Kontilis conducted a subsequent complaint visit to issue final findings for the complaint allegation above. LPA met with Omar Garcia, Program Manager and Monica Gomez, Clinical Case Manager. LPA explained the purpose of the visit. During the investigation, on 6/14/2023, LPA reviewed relevant documents for R1, conducted interviews with staff at 12:41 pm, 12:48 pm, 12:52 pm, 12:55 pm, and 4:40 pm, and conducted interviews with residents at 2:08 pm, 2:09 pm, 2:12 pm, and 2:15 pm. On the allegation: Staff did not meet resident's hygiene/grooming needs. It was alleged that R1 appeared “disheveled” with hair growing out of their nose, had an unkempt beard, hair growing out of their ears and wax in the ears. Staff told the reporting party they could not force R1 to shower or help with grooming if R1 refused. Interviews with residents at the facility revealed the staff help them with hygiene and grooming needs, and their needs are being met. Interviews wRead the full finding— CDSS inspection report, June 14, 2023 · control 29-AS-20230124170445

Licensing Program Analyst (LPA) Kristin Kontilis conducted a subsequent complaint visit to deliver findings for the above allegations. LPA met with Jennifer Farley, Program Director; Enedelia Avila, Staff in Charge; and Antonela Milito, Program Manager and explained the reason for the visit. On 01/24/2023, the Department received a complaint regarding allegations of Neglect/Lack of Supervision. It was alleged that Resident #1 (R1) sustained fractures while in care; developed a urinary tract infection (UTI) while in care resulting in sepsis; and the facility staff failed to seek medical attention for R1. The complaint was referred to the Community Care Licensing Investigations Branch (IB) and assigned to Investigator Peter Zertuche. On 01/25/2023, from 1:30 pm to 3:30 pm, Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced initial 10-day complaint investigation based on the allegations stated above. LPA Kontilis met with Omar Garcia, Program Manager and Enedelia AvRead the full finding— CDSS inspection report, April 28, 2023 · control 29-AS-20230124170445

On 3/6/2023 at 1:00 pm, Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced initial visit for this complaint. LPA met with Jennifer Farley, Program Director and Enedelia Avila, Program Administrator,, and explained the purpose of the visit. On the allegation: Staff did not provide access to a resident's records. To investigate the complaint, LPA reviewed documents including a Subpoena for records dated 1/26/2023 for former Resident 1 (R1)’s entire resident file, and an attached authorization stating that R1’s responsible party authorized the attorney to handle the claim, signed 1/25/2023 by R1’s responsible party. The subpoena states “Evidence Code 1158 of the California Standard Code states the following: Failure to make such records available, during business hours, within five (5) days after the presentation of the written authorization, may subject the person or entity having custody or control of the records to liability for all reasonable expenses, includingRead the full finding— CDSS inspection report, March 6, 2023 · control 29-AS-20230228133212