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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157206261
Report Date: 03/09/2024
Date Signed: 03/09/2024 11:09:38 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/05/2024 and conducted by Evaluator Shawna Doucette
COMPLAINT CONTROL NUMBER: 24-AS-20240305125134
FACILITY NAME:SAILS XFACILITY NUMBER:
157206261
ADMINISTRATOR:TUCKER, JACQUELINEFACILITY TYPE:
735
ADDRESS:7617 INDIAN GULCH STTELEPHONE:
(661) 473-2333
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93313
CAPACITY:5CENSUS: 5DATE:
03/09/2024
UNANNOUNCEDTIME BEGAN:
09:53 AM
MET WITH:Administrator Jacqueline TuckerTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff do not maintain the facility free of mold
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Shawna Doucette contacted the facility to commence a complaint investigation. LPA identified herself and explained the purpose of the visit and was granted entry by Staff Cynthia Aparicio. Staff contacted the Administrator who responded to the facility to assist with the investigation.

LPA toured the facility and checked the food supply. LPA interviewed and and residents.

Based on observation and interviews, although the stair was broke facility staff contacted maintenance and had it repaired within a timely manner. LPA observed the staircase to not have any broken stairs.

Based on observation and interviews, the leak was in the shower head which was fixed, however LPA did observe mold in the upstairs bathroom. LPA took photos.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2024
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 5
Control Number 24-AS-20240305125134
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: SAILS X
FACILITY NUMBER: 157206261
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/15/2024
Section Cited
CCR
80087(a)
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80087 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety. This requirement was not met as evidenced by Licensee did not keep the upstairs shower free of mold which poses a potential.
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Plan of Correction POC Licensee agrees to clean the upstairs shower and submit a photo by POC due date 03/15/24
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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: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 24-AS-20240305125134
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: SAILS X
FACILITY NUMBER: 157206261
VISIT DATE: 03/09/2024
NARRATIVE
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Based on the Departments interviews and observation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Article 8, is being cited on the attached LIC 9099D.


A copy of this report was provided to Administrator with plans of correction and appeal rights.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5