Devereux Foundation - Weisman Center (RCFE)

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced Annual required inspection at the above-named facility. Upon arrival, LPA was greeted by Monica Gomez, Clinical Case Manager and explained the purpose of the visit. Sydney Steiner, Program Manager accompanied LPA during the visit. Jennifer Farley, Program Director was unavailable at the time of the visit. LPA explained the purpose of the visit. There are currently fifteen (15) clients residing in the facility. At the time of arrival, there were eight (8) clients present with five (5) staff on duty. Clients not present were attending day programs and/or appointments away from the facility. Entrance interview conducted. The facility is a one-story home to Clients with intellectual/developmental disabilities, has a fire clearance for 15 non-ambulatory clients and a hospice waiver for 2 clients. There is one resident currently on hospice. The facility contracts with Tri-Counties Regional Center. A tour of the physical environment and accommodations were assessed, and the following was noted: LPA observed the required posting of the complaint poster and Resident’s Rights. LPA inspected the one-story facility for fire safety, personal accommodations, and food service. The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, doors, floors and floor coverings were checked. At approximately 2:25 pm, LPA observed approximately 22 areas throughout the facility in need of patching and painting. Said areas included hallways, door jams, and other areas. LPA observed four (4) fire extinguishers serviced on 3/14/2026 and 4/27/2026, two (2) carbon monoxide detectors in good working order, 27 smoke alarms, and an automatic sprinkler system throughout the building. Please continue to 809-C, Pg 2. The kitchen area was sufficiently stocked with two-day perishables and seven days of non-perishables. Frozen foods are properly wrapped and stored appropriately. LPA observed the kitchen cabinets, refrigerators, stove, and counters are clean. A weekly house meeting is conducted with Staff in Charge (SIC) to discuss clients’ activities and planning for the activities for the upcoming week. Clients participate at will in activities with music appreciation, virtual reality tours, holiday celebrations, birthdays, self-accomplishment celebrations, weekly acknowledgements, painting projects, Bingo, and greenhouse planting. Local excursions include going to movie theaters, lunch outings, breakfast outings, museums, shopping, concerts in the park, and beach outings. Medications and First Aid kits are kept in the locked staff office in a locked medication cart. Meals are prepared by the staff and staff assist with meal distribution and assisting clients with safety precautions and special diet accommodations. Snacks are available throughout the day. Clients may volunteer to complete chores throughout the facility if desired. The front entrance consists of an open porch with a bench located near the front door. The facility maintains a comfortable temperature and there are no bodies of water. The facility has twelve (12) bedrooms. Bedrooms #1, 5, and 9 are shared bedrooms. Bedroom #9 has a private bathroom for the two occupants. Bedrooms #11 and 12 are single rooms with a shared bathroom between the two rooms. Bedrooms #2, 3, 4, 6, 7, 8 and 10 are private bedrooms. There are 5 bathrooms with access from the hallway available to all clients and staff. The bathrooms have secure grab bars. Personnel documents reviewed revealed an adequate number of training hours has been completed; health screenings were complete, and all staff have been properly associated to the facility. Clients records reviewed revealed admission agreements, appraisals, needs and services plans, and health screenings were complete. On 3/26/2026, the facility self-reported an incident stating on 3/23/2026 Client 1 (C1) was administered 1 tablet of Lorazepam 2mg as a PRN. Dr.’s order states ‘administer 1 tablet of Lorazepam 1 mg and wait one hour before administering Lorazepam 2mg'. Staff 1 (S1) did not follow Client’s PRN order per Doctor's prescription and protocol. On 1/22/2026, the facility self-reported an incident wherein on 1/16/2026 Client 2 (C2) was administered PRN Lorazepam 1 mg tablet from another client’s medication supply. Program Manager stated S1 and S1 were counseled on the errors, conducted re-training, and are no longer employed by the Licensee. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D): Exit interview conducted. Copy of report and Appeal Rights issued at the time of the visit.the state’s words, verbatim · CDSS document, Jul 21, 2026

The state marks this report as 8 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Staff did not adhere to resident’s admission agreement. Resident developed pressure injury while in care. Staff altered resident's records. Staff mismanaged resident's medication. Staff did not safeguard resident’s personal belongings.

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced subsequent complaint visit to deliver final findings for the above-stated allegations. During today’s visit, LPA met with Program Director Jennifer Farley, Clinical Case Manager Monica Gomez, and Director of Risk and Quality Management Eric Christiansen. LPA explained the purpose of the visit. LPA Kontilis conducted the initial visit on 5/6/2025 from approximately 11:30 am – 3:30 pm at which time LPA conducted interviews and obtained documents pertaining to the investigation. LPA conducted a subsequent complaint visit on 5/18/2026 from approximately 10:45 am to 4:00 pm to conduct additional interviews and obtain additional documents pertaining to the investigation. On the allegation, Staff did not adhere to resident’s admission agreement: It has been alleged that the facility gave a 30-day notice to terminate Resident 1’s (R1’s) residency and the facility declined to accept R1 back into the facility after hospitalization. Records reviewed and interviews conducted revealed R1 was Please continue to 9099-C, Pg 2. Unsubstantiated hospitalized on 11/21/2024. On 12/31/2024, R1 was re-assessed by facility’s Clinical Case Manager, LVN, and Program Manager. Following the assessment, Program Manager sent an email to R1’s TCRC Service Coordinator with a CC to R1’s responsible party as well as other Facility Care Team members with an update that R1’s care needs had significantly changed and R1 needed a higher level of care, such as a skilled nursing facility (SNF), which is above what their facility can provide. The email further stated if R1’s condition improved, R1 could be re-evaluated for potentially returning to the facility. Record review revealed TCRC Service Coordinator was asked if TCRC would continue to fund R1’s bed while R1 recovered and could be re-assessed for potential return to the facility. Interviews conducted revealed the facility did not issue a 30-day eviction notice to R1 and/or R1’s responsible party. Records reviewed revealed TCRC Service Coordinator and R1’s responsible party responded to facility staff stating they would like to release R1’s bed and the release date was backdated to 1/3/2025. Based on interviews conducted and records reviewed, the allegation that staff did not adhere to resident’s admission agreement is deemed Unsubstantiated at this time. On the allegation, Resident developed pressure injury while in care. It is has been alleged that R1 developed a Stage 3 wound to R1’s Right Leg Extremity (RLE) while residing in the facility. Records reviewed revealed hospital care management notes dated 12/11/2024 state R1 developed the wound while at the facility. R1 was admitted into the facility on 6/14/2023. Upon admission, R1 was assessed by the facility LVN at which time, an open wound was discovered, and the treatment team made the decision to send R1 out to be evaluated and to have the open wound staged. Records review revealed R1’s wounds and bruises of unknown origin were observed at the time of R1’s admission into the facility and subsequent reports were submitted to CCLD, TCRC, Long Term Care Ombudsman (LTCO) and local law enforcement as required. Over the duration of R1’s care while residing in the facility, there was a change in condition where R1’s health was declining, their abilities were declining, and R1 became less mobile, less responsive, and less interactive with others. As R1 began to decline and became less mobile, R1 was spending more time in bed and in a wheelchair and developed pressure ulcers. The facility submitted an exception request for a “Prohibited Health Condition” to Community Care Licensing Division (CCLD) and the exception request was granted on 6/23/2023. A second exception request for a prohibited health condition was requested and granted by CCLD on 12/4/2024 specifically noting “Stage 3 Pressure Injuries to the right ankle and toe”. Interviews conducted revealed R1’s Responsible Party was informed that R1 had developed a Stage 3 pressure ulcer and in order to allow R1 to remain residing in the facility, R1’s responsible party requested the second exception. Interviews conducted revealed R1’s responsible party was aware that the wound care must Please continue to 9099-C, Pg 3. come from the outside wound care agency and the facility staff are not allowed to provide such services. Prior to R1’s admission into the hospital on 11/21/2024, the wound care nurse attended to R1 twice each week and on the nurse’s regularly scheduled visit, the nurse noted on 11/20/2024 signs and symptoms of possible infection to R1’s RLE. At that time, the wound care nurse instructed the care team to send R1 out for care to the hospital if R1 developed a fever. Records review revealed upon R1’s admission into the hospital on 11/21/2024 and the hospital care management notes cited the wound on 12/11/2024 and during that time, R1 remained in the hospital. Interviews conducted revealed Program Director stated although R1 may have developed a pressure injury while in care, it is at no fault of the facility and it is noted that R1 has had a history of the wounds and the facility took all the appropriate and required measures to ensure R1’s proper care of wounds including but not limited to requesting two exceptions for Prohibited Health Conditions on two separate occasions and bringing in outside wound care specialists who provided the facility with guidance and instruction for R1’s care. Based on the interviews conducted and records reviewed, the allegation that Resident developed a pressure injury in care is deemed Unsubstantiated at this time. On the allegation, Staff altered resident records: It is alleged that facility staff did not follow proper procedures when documenting self-administration of R1’s Clonidine 0.3mg/24 hr patch. Responsible Party voiced concern that the Medication Administration Record (MAR) from 12/1/2024 through 12/31/2024 was documented as to R1 having been administered the medication on a daily basis. Record review and interviews conducted revealed R1 was out of the facility from 11/21/2024 through 12/31/2024. Interviews conducted revealed R1’s MAR for the month of December 2024 indicates “A” meaning R1 was “away” from the facility and the medications were not administered. Based on records reviewed and interviews conducted, the allegation that Staff altered resident’s records is deemed Unsubstantiated at this time. On the allegation, Staff mismanaged resident medication: It has been alleged that staff mismanaged R1’s Clonidine 0.3mg/24 hr patch. Responsible Party voiced concern that the Medication Administration Record (MAR) indicates the medication was administered from 12/1/2024 through 12/31/2024. Interviews conducted with Program Director indicated records were not mismanaged as R1 was in the hospital throughout the month of December 2024 and documentation does not indicate medications were administered. Further, Program Director stated the MAR record reveals “A” for “away” for all days in the month of December 2024 as a standard procedure to indicate medications have not been administered. Based on records reviewed and interviews conducted, the allegation that Staff mismanaged resident medications is deemed Unsubstantiated at this time. Please continue to 9099-C, Pg 4. On the allegation, Staff did not safeguard resident’s personal belongings: It has been alleged that facility staff failed to provide R1’s responsible party with R1’s personal belongings such as November 2024 Medication Administration Record (MAR), leftover Ensure Nutritional Supplement, and wound care products. Interviews conducted revealed R1's responsible party obtained all of R1's personal belongings including medications and Medication Administration Records for the entire time R1 resided in the facility. Interview conducted revealed all of the belongings requested were provided to R1's responsible party on or about 1/8/2025. Interview conducted with facility LVN revealed all Medication Administration Records were given to R1's responsibility party. Records reviewed and interviews conducted revealed November 2024 MAR was also sent via email from Records Tech to R1’s responsible party on 11/13/2025 at 2:59 pm. Interview conducted with Facility LVN revealed at the time of R1’s hospitalization on 11/21/2024, LVN informed R1’s responsible party that R1 had no remaining containers of Ensure Nutritional Supplement. Program Director stated the facility does not retain wound care supplies because they do not provide wound care services and the outside agencies are responsible for all wound care supplies. Based on interviews conducted and records reviewed, the allegation that Staff did not safeguard resident’s personal belongings is deemed Unsubstantiated at this time. Exit interview conducted. No deficiencies noted. Copy of report issued at the time of the visit.the state’s words, verbatim · CDSS document, May 20, 2026 · control 29-AS-20250501131300

Allegation investigated: Staff illegally evicted resident in care.

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced subsequent complaint visit to deliver final findings for the above-stated allegation. During today’s visit, LPA met with Program Director Jennifer Farley and Clinical Case Manager Monica Gomez and explained the purpose of the visit. LPA Kontilis conducted the initial visit on 5/6/2025 from approximately 11:30 am – 3:30 pm at which time LPA conducted interviews and obtained documents pertaining to the investigation. On the allegation, Staff illegally evicted resident in care: It was alleged that when Resident 1 (R1) was being discharged from the hospital, the facility staff did not accept (R1), and the facility initiated their own 30-day notice to R1 and R1’s responsible party. Interviews conducted and records reviewed revealed R1 was hospitalized on 11/21/2024 and the hospital was preparing to discharge R1 at an unknown date. Interviews conducted revealed the hospital was seeking to discharge R1 but had not yet been given a discharge date. Interviews conducted revealed facility staff informed Tri-Counties Regional Center’s (TCRC’s) Service Please continue to 9099-C, Pg 2. Unsubstantiated Coordinator and R1’s responsible party that the Facility’s care team would need to evaluate R1 at the hospital prior to R1’s discharge back to the facility in order to assess R1 and ensure that the facility staff could provide the necessary support to meet R1’s needs. On 12/31/2024, interviews conducted revealed the facility care staff consisting of the Clinical Case Manager, the facility LVN, and the facility Program Manager evaluated R1 at the hospital where R1 was observed to not open their eyes, did not acknowledge verbal communication or respond to being touched. Interviews conducted revealed at the time of the assessment, R1 was sleeping, laying on their back with R1’s legs contracted almost reaching their chest, and R1’s arms were also laying and contracted against R1’s chest. Prior to the facility’s assessment, interviews conducted revealed R1’s responsible party stated R1 was able to self-feed and had been evaluated for adaptive equipment to assist R1 feeding themselves and was able to conduct other daily living needs. At the time of the assessment, interviews conducted revealed R1 was unable to feed themselves, R1 had to be fed, and the hospital nurse assisting R1 stated R1’s feeding could last anywhere from 45 minutes to 1½ hours or more depending on R1’s ability to respond. Interviews conducted further revealed during the assessment, R1 was observed to have open wounds to their toes and ankle and a pressure ulcer on the buttocks; facility Clinical Case Manager requested a copy of R1’s Physical Therapy/Occupational Therapy and the Doctor’s recommendations but the hospital staff stated they did not have it on hand and would send the information to the facility Clinical Case Manager and the Program Manager. Interviews conducted revealed when the Facility Clinical Case Manager observed R1, R1 was unable to self-administer their medications and observed the hospital nurse administer R1’s medication to R1 on a spoon with either yogurt or apple sauce by placing the spoon in R1’s mouth. Interviews conducted further revealed Facility Case Manager inquired about a quadriplegic wheelchair for R1, the hospital case worker informed the facility Clinical Case Manager that R1 was completely “bed-bound”, and no report had been made to initiate the use of a quadriplegic wheelchair. Records reviewed and interviews conducted revealed prior to hospital discharge, R1’s care needs had significantly changed and new diagnoses were identified including dementia, peripheral arterial disease, and mild hyperkalemia. At the time R1 was to be discharged from the hospital, R1’s responsible party reported to facility staff that R1 was able to self-feed, self-administer medications, and R1 had been evaluated for adaptive equipment to assist R1 with R1’s Assisted Daily Living (ADLs) needs. Interviews conducted and records reviewed revealed the facility care team informed R1’s responsible party that the facility care team could not give an immediate response on whether or not the facility could accept R1 back into the facility until the documentation was received to provide to the facility's Utilization Review Team for determination of whether R1’s needs could be met. Records reviewed and interviews conducted, revealed on 1/3/2025 Facility Please continue to 9099-C, Pg 2. Program Manager sent an email to R1’s TCRC Service Coordinator with a CC to R1’s responsible party as well as other Facility Care Team members with an update that R1’s care needs had significantly changed and R1 needed a higher level of care above what their facility can provide, such as a skilled nursing facility (SNF). The email further stated if R1’s condition improved, R1 could be re-evaluated for potentially returning to the facility. Record review revealed TCRC Service Coordinator was asked if TCRC was willing to hold the bed for R1 and would TCRC fund R1’s position until R1 was re-assessed and determined to be able to return to the facility. Records reviewed revealed TCRC’s response was directed to R1’s responsible party requesting a decision on whether they wanted to keep R1’s bed open and requested from the facility Program Manager how long the bed could be kept available. Record review revealed TCRC communicated to facility Program Manager stating R1’s responsible party replied stating they would like to release the room and R1’s responsible party will start the move-out process. Record review revealed on 1/7/2025, TCRC confirmed the release date of R1’s bed and was to be backdated to 1/3/2025. Interviews conducted revealed on 1/7/2025 R1’s responsible party came to the facility and began removing R1’s personal belongings and retrieved the remaining belongings on 1/8/2025. Based on records reviewed and interviews conducted, the allegation that staff illegally evicted resident in care is Unsubstantiated at this time. Exit interview conducted. No deficiencies noted. Copy of report issued at the time of the visit.the state’s words, verbatim · CDSS document, May 18, 2026 · control 29-AS-20250501131300

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff consuming alcohol while caring for client(s), impairing their ability to provide care, which presents a risk to client(s) in care.

Licensing Program Analyst (LPA) Kristin Kontilis conducted a subsequent complaint visit to issue final findings on this investigation. LPA met with Jennifer Farley, Program Director and Monica Gomez, Clinical Case Manager. LPA explained the purpose of the visit. During the investigation, On 2/13/2026 from 12:19 pm to 3:30 pm, LPA Kontilis conducted interviews and obtained relevant documents pertaining to the investigation. Adela Cortinas, Quality Assurance Supervisor, Tri-Counties Regional Center (TCRC) accompanied LPA during the visit. On the allegation, Staff consuming alcohol while caring for client(s), impairing their ability to provide care, which presents a risk to client(s) in care: The concern is that Staff consumed alcoholic beverages while caring for Client 1 (C1) including transporting C1 to an appointment. Interviews conducted revealed when Staff 1 (S1) transported C1 to their medical appointment in the facility vehicle, S1 stopped at a convenience store/liquor store and purchased a non-alcoholic beverage and a pastry. Interviews conducted further Please continue to 9099-C, Pg 2. Unsubstantiated revealed when S1 stopped at the convenience store/liquor store, C1 was left unattended in the facility vehicle causing C1 to feel unsafe. During S1’s interview, S1 stated S1 realized stopping at the store was poor judgement and that the purchased item(s) could have been “misinterpreted”. S1 further stated a non-alcoholic beverage was purchased and no alcoholic beverages were purchased at that time. Although C1’s testimony has remained consistent throughout the investigation, no further corroborating evidence was obtained to prove S1 purchased or consumed alcohol. Based on the interviews conducted, the allegation that Staff consumed alcohol while caring for client(s), impairing their ability to provide care, which presents a risk to client(s) in care is Unsubstantiated at this time. The lack of supervision when S1 left C1 alone in the car will be addressed in a separate case management visit. Exit interview conducted. Copy of report issued at the time of the visit.the state’s words, verbatim · CDSS document, Feb 18, 2026 · control 29-AS-20260209115957

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kristin Kontilis conducted a Case Management visit to address deficiencies noted during Complaint Control #29-AS-20260209115957. The Case Management visit is being conducted to address CCLD’s concern that during the course of the investigation, Staff 1 (S1) admitted leaving Client 1 (C1) alone in the facility vehicle when C1 was being transported to an appointment leaving C1 to feel “unsafe”. Interviews conducted revealed S1 stated they realized stopping at a convenience store to make a purchase and leaving C1 alone in the vehicle without supervision was poor judgement. 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 issued at the time of the visit. Appeal Rights issued.the state’s words, verbatim · CDSS document, Feb 18, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Feb 20, 2026

87468.2(a)(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on interviews and record review, the Licensee did not comply with the section cited above when staff left a client alone and unsupervised in the facility vehicle which poses an immediate personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 18, 2026

Plan of correction: Program Director agrees to provide written disciplinary action for S1 and will conduct a Personal Rights re-training for S1. Written discplinary action and proof of re-training will be sent via email to LPA no later than due date. Proof of re-training will include date of training, description, S1's signature, and who conducted the training.

Allegation investigated: Staff did not follow reporting requirements.

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. Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 13, 2026 · control 29-AS-20260209115957

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Staff did not provide responsible party with resident's records.

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 for documents not collected per the responsible parties written request via email to the LPA's email no later than end of business day of November 14, 2025. CONTINUED on LIC9099-C Unsubstantiated As to the allegation of, "Staff did not provide responsible party with resident's records" It was alleged that, this facility has "not (provided) their internal and actual records recordings/documentation by (the facility) personnel." It was discovered through interviews on 11/12/2025 of Administrative Staff S1, S2, S3, and S4 that Resident 1 (R1) resided at the facility from June 2023 through November 21, 2025. On 11/12/2025, It was also determined through interviews with S1, S2, S3, and S4, that R1's responsible party (F1) was confirmed. LPA Jeffries presented a written request for documentation not previously provided to the facility from F1 for R1 additional documentation requested. Administrative staff presented LPA with all documents requested for R1 in F1's written request. LPA noted that documentation on written request that had resident information in addition to R1 which was visually verified by LPA. LPA noted that facility has presented documentation to F1 for R1 prior to this allegation as noted in an interview on 11/10/2025 by LPA with F1,, and noted in the initial complaint filed as well as emails collected by LPA on 11/12/2025 from facility Administrative Support Coordinator Mory Alvarez. LPA noted that documentation that could be sent to F1 per F1's written request was collected and documents with confidential information of residents that included R1 was visually verified by LPA on 11/12/2025. Additionally, facility provided an explanation of documentation for not sent to F1 due to additional resident privet information on those documents in an email to F1 explaining that documents not provided per the written request were due to resident privacy rights indicating that other resident information were noted on documents that were not provided. Based on the admission of F1 on 11/10/2025 of prior documents submitted by evidence of previous documentation submitted to F1 by past emails provided by Administrative Support Coordinator, and the email submission of documents to F1 written request on the complaint visit on 11/12/2025, there is not sufficient evidence at this time to support the allegation of, "Staff did not provide the responsible party with resident's records." and is unsubstantiated at this time. Exit interview, report read, and report provided.the state’s words, verbatim · CDSS document, Nov 12, 2025 · control 29-AS-20251107163849

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced Annual required inspection at the facility. Upon arrival, LPA was greeted by Antonela Milito, Program Manager. Monica Gomez, Clinical Case Manager accompanied LPA during the visit. Jennifer Farley, Program Director was unavailable at the time of the visit. LPA explained the purpose of the visit. There are currently fifteen (15) clients residing in the facility. At the time of arrival, there were fifteen (15) clients present with five (5) staff on duty. Entrance interview conducted. The facility is a one-story home to Clients with intellectual/developmental disabilities, has a fire clearance for 15 non-ambulatory clients and a hospice waiver for 2 clients. There is currently one resident on hospice. The facility contracts with Tri-Counties Regional Center. A tour of the physical environment and accommodations were assessed, and the following was noted: LPA observed the required posting of the complaint poster and Resident’s Rights. LPA inspected the one-story facility for fire safety, personal accommodations, and food service. The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, doors, floors and floor coverings were checked. The facility was seen to be in good repair inside and outside. LPA observed four (4) fire extinguishers serviced on 4/15/2025 and 4/16/2025, two (2) carbon monoxide detectors in good working order, 27 smoke alarms, and an automatic sprinkler system throughout the building. The kitchen area was sufficiently stocked with two-day perishables and seven days of non-perishables. Frozen foods are properly wrapped and stored appropriately. LPA observed the kitchen cabinets, refrigerators, stove, and counters are clean. Please continue to 809-C, Pg 2. A weekly meeting is conducted with Staff in Charge (SIC) to discuss clients’ activities and planning for the activities for the upcoming week. Clients participate at will in activities with holiday celebrations, birthdays, self-accomplishment celebrations, weekly acknowledgements, painting projects, Bingo, and greenhouse planting. Clients recently participated in an excursion to Disneyland and Circus Vargas. Local excursions include going to movie theaters, lunch outings, breakfast outings, museums, shopping, concerts in the park, and beach outings. Medications and First Aid kits are kept in the locked staff office in a locked medication cart. Meals are prepared by the facility cook. Staff assist with meal distribution and assisting clients with safety precautions and special diet accommodations. Snacks are available throughout the day. Clients may volunteer to complete chores throughout the facility if desired. The front entrance consists of an open porch with a bench located near the front door. The facility maintains a comfortable temperature and there are no bodies of water. The facility has twelve (12) bedrooms. Bedrooms #1, 5, and 9 are shared bedrooms. Bedroom #9 has a private bathroom for the two occupants. Bedrooms #11 and 12 are single rooms with a shared bathroom between the two rooms. Bedrooms #2, 3, 4, 6, 7, 8 and 10 are private bedrooms. There are 5 bathrooms with access from the hallway available to all clients and staff. The bathrooms have secure grab bars. Personnel documents reviewed revealed an adequate number of training hours has been completed; health screenings were complete, and all staff have been properly associated to the facility. Clients records reviewed revealed admission agreements, appraisals, needs and services plans, and health screenings were complete. Medications are given as prescribed. Exit interview conducted. No deficiencies noted. Copy of report issued at the time of the visit.the state’s words, verbatim · CDSS document, Jul 16, 2025

Allegation investigated: Staff did not provide responsible party with resident's records.

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 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.the state’s words, verbatim · CDSS document, May 23, 2025 · control 29-AS-20250102094412

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(c)(1) · Plan of correction due date: May 28, 2025

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: 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.the state’s words, verbatim · CDSS document, May 23, 2025

Plan of correction: 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.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced case management incident visit to the facility. LPA met with Antonela Molito, Program Manager, Jennifer Farley, Program Director, and Monica Gomez, Clinical Case Manager and explained the purpose of the visit. Stephanie Cole and Adela Cortinas, Quality Assurance Specialists, Tri-Counties Regional Center accompanied LPA during the visit. During today’s visit, LPA obtained documents pertaining to the investigation and conducted in-person interviews. On 4/18/2025 and 4/19/2025, CCL received incident reports (SIR) from the facility for R1. According to the SIRs, R1 made inappropriate comments to staff, but stated they were “joking.” An addendum to the SIR sent 4/23/2025 stated R1 was interviewed on two separate occasions by staff. R1 stated they did not have any inappropriate interactions with staff, and it was supposed to be a joke. Per the SIRs, R1 has a history of making inappropriate comments to staff. On 5/2/2025, QAS Cole and Cortinas and Gomez, Clinical Case Manager interviewed R1. After the interview with QAS TCRC representatives, R1 stated to Gomez that R1 did not have inappropriate interactions with staff and the stories were “made up”. No deficiencies were issued during this visit. The LPA may return at a later date if it is determined deficiencies are warranted. Exit interview conducted. Copy of report issued at the time of the visit.the state’s words, verbatim · CDSS document, May 6, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced Annual required inspection at the facility. Upon arrival, LPA was greeted by Omar Garcia, 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. There are currently fourteen (14) clients residing in the facility. At the time of arrival, there were fourteen (14) clients present with five (5) staff were on duty. Entrance interview conducted. The facility is a one-story home to Clients with intellectual/developmental disabilities, has a fire clearance for 15 non-ambulatory clients and a hospice waiver for 2 clients. Currently, there are no residents on hospice. The facility contracts with Tri-Counties Regional Center. A tour of the physical environment and accommodations were assessed, and the following was noted: LPA observed the required posting of the complaint poster and Resident’s Rights. LPA inspected the one-story facility for fire safety, personal accommodations, and food service. The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, doors, floors and floor coverings were checked. The facility was seen to be in good repair inside and outside. LPA observed five (5) fire extinguishers serviced on 4/3/2024, two (2) carbon monoxide detectors in good working order, 27 smoke alarms, and an automatic sprinkler system throughout the building. The kitchen area was sufficiently stocked with two-day perishables and seven days of non-perishables. Frozen foods are properly wrapped and stored appropriately. LPA observed the kitchen cabinets, refrigerator, stove, and counters are clean. A weekly meeting is conducted with Staff in Charge (SIC) to discuss clients’ activities and planning for the activities for the upcoming week. Clients participate at will in activities with holiday celebrations, birthdays, self-accomplishment celebrations, weekly acknowledgements, painting projects, Bingo, and greenhouse planting. A plan is in progress for the residents to participate in a day trip to Disneyland which will include groups of five residents in three different sessions. Please continue to 809-C.Page 2 Clients also participate independently in arts and crafts, excursions to the local eateries, museums, and parks, entertainment places, walks, and places of worship. Medications and First Aid kits are kept in the locked staff office in a locked medication cart. Meals are prepared by the facility cook. Staff assists with meal distribution and assisting clients with safety precautions and special diet accommodations. Snacks are available throughout the day. Clients may volunteer to complete chores throughout the facility if desired. The front entrance consists of an open porch with a bench located near the front door. The facility maintains a comfortable temperature and there are no bodies of water. The facility has twelve (12) bedrooms. Bedrooms #1, 5, and 9 are shared bedrooms. Bedroom #9 has a private bathroom for the two occupants. Bedrooms #11 and 12 are single rooms with a shared bathroom between the two rooms. Bedrooms #2, 3, 4, 6, 7, 8 and 10 are private bedrooms. There are 5 bathrooms with access from the hallway available to all clients and staff. The bathrooms have secure grab bars. All staff have been properly associated to the facility. Record review and interviews conducted revealed facility staff have have not received the yearly 20 hours of training in dementia, postural supports, restricted health conditions, and hospice care. The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted. Due to technical difficulties copy of the report and appeal rights were provided via email.the state’s words, verbatim · CDSS document, Jul 10, 2024

Type of visit: Case Management - Incident

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. 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.the state’s words, verbatim · CDSS document, Feb 13, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Feb 15, 2024

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: 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.the state’s words, verbatim · CDSS document, Feb 13, 2024

Plan of correction: 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 description of training. Training sign-in sheet to be provided to LPA via email. CIVIL PENALTTY ASSESSED