Complaint Investigation Report

(Pg2) On 07/07/2021, from 12:40pm to 1:50pm, Licensing Program Analyst (LPA) Toan Luong conducted an initial 10 Day complaint inspection at Devereux - Casa Feliz. The visit was conducted on-site with Quality Management Manager (QMM) Leticia Villarreal and Assistant Clinical Director Clare Penny. During the visit, LPA Luong toured the facility with QMM and requested documents pertinent to the investigation. The LPA determined further investigation was required.

On 08/12/2021, Investigator Seng conducted an interview with Santa Barbara County Ombudsman; on 08/16/2021, with R1’s representatives; on 08/20/2021, with the facility clinical case manager; on 08/20/21, with staff and residents; and on 08/23/2021, with former staff and current staff.

Investigator Seng reviewed copies of facility records and University of California Santa Barbara (UCSB) Campus Police Incident Reports. R2’s diagnosis is listed as mild intellectual disability, cerebral palsy and seizure disorder. R2’s Individual Program Plan (IPP) dated 01/22/2021, states R2 exhibits the following disruptive social disorders: verbal hostility, resistiveness, self-injurious behavior with no apparent injuries, physical aggression toward staff and peers, and emotional outbursts. R2’s plan also states “it is important to R2 to have direct care staff one to one support and attention as often as R2 can”. Program Director Farley clarified that there is a section in the IPP that distinguish what is important to the resident versus what is important for the resident and the desire to have one to one support was that of R2s and not of the treatment team upon admission.

Investigator Seng reviewed incident reports from UCSB Campus Police. There were no reports filed for a sexual assault incident between R1, R2, and Resident #3 (R3), aside from two unrelated reports provided. The unrelated reports were related to R2 grabbing R3’s shirt. The other incident was related to R1 intervening as R2 had a behavior. All incidents from the reports were handled by Devereux administration as the police determined that no crime had occurred.

A review of the staff schedule reflected that there is one staff assigned to each shift – am, pm, and overnight. At the time the complaint was filed, there were a total of four (4) residents residing at the facility, two (2) of which had seizure disorders that require additional supervision, along with behaviors associated with their diagnoses. (Continued on 9099C)