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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206261
Report Date: 01/11/2024
Date Signed: 01/11/2024 03:27:27 PM

Document Has Been Signed on 01/11/2024 03:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
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:
01/11/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:14 PM
MET WITH:Administrator Jacqueline TuckerTIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Shawna Doucette arrived at the facility unannounced to conduct a case management inspection regarding a CPI hold that occurred on 12/19/23. LPA met with Administrator Jacqueline Tucker.

During the course of the Case Management investigation, LPA reviewed C1's file/IPP and interviewed staff. LPA reviewed staff CPI training. CPI traiining for S1 is current and expires 2/24/24 and S2's CPI training is expired as of 10/8/23.

Refer to 809D.


A copy of this report was provided to the Administrator.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE: DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/11/2024 03:27 PM - It Cannot Be Edited


Created By: Shawna Doucette On 01/11/2024 at 01:03 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: SAILS X
FACILITY NUMBER: 157206261

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/05/2024
Section Cited
CCR
85165(b)(2)

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85165 Emergency Intervention Staff Training (b) Staff who use, participate in, approve or provide visual checks of manual restraint or seclusion, shall have a minimum of sixteen hours of emergency intervention training and be certified for having
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Plan of Correction POC Licensee agrees to submit current CPI training for S2 by POC due date 02/5/24.
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successfully completed the training. (2) Staff shall maintain valid certification. This requirement was not met as evidenced by Licensee did not ensure S2 has current CPI training when S2 conducted a CPI hold on C1 on 12/19/23 which poses a potential health safety and/or personal rights risks to clients 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.
SUPERVISOR'S NAME:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Shawna Doucette
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2024


LIC809 (FAS) - (06/04)
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