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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208892
Report Date: 01/31/2023
Date Signed: 01/31/2023 12:16:01 PM

Document Has Been Signed on 01/31/2023 12:16 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 VIFACILITY NUMBER:
157208892
ADMINISTRATOR:BARNHARD, RAYMONDFACILITY TYPE:
735
ADDRESS:10117 ST ALBANS AVETELEPHONE:
(661) 473-2340
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY: 5CENSUS: 5DATE:
01/31/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Administrator Jessica DelgadilloTIME COMPLETED:
12:20 PM
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On 01/31/23, Licensing Program Analyst (LPA) Yang arrived at the facility unannounced to conduct a case management inspection follow up visit from 10/21/22 on written incident report received.

LPA were greeted by caregiver Robert Gobea. LPA introduce self, stated the purpose of the visit and were granted entry into the facility. LPA requested to meet with Administrator. Administrator Jessica Delgadillo was called and arrived shortly.

On 10/19/2022, the department received self-reported written incident regarding Staff 1(S1) punched Client 1 (C1) in the face resulting in a black eye.

During the course of the investigation, the Department conducted interviews and reviewed records and based on interviews conducted, S1 hit C1 leaving C1 with a black eye.

Per California Code of Regulations, Title 22, Division 6, Chapter 1, a deficiency is being cited on the attached 9099-D. As a result of the incident, S1 hit C1 leaving C1 with a black eye, a violation that warrants a civil penalty assessment. A Civila Penalty is being assessed.

Exit interview was conducted. A copy of this report and appeal rights were given to Administrator, whose signature confirms receipt of this report.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2023
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 01/31/2023 12:16 PM - It Cannot Be Edited


Created By: Mai Yang On 01/31/2023 at 11:39 AM
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 VI
FACILITY NUMBER: 157208892

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/01/2023
Section Cited
CCR
85065(b)

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85065 (b) Personnel Requirements (b)The licensee shall employ staff as necessary to ensure provision of care and supervision to meet client needs.

This requirement was not met as evidenced by:

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Facility shall review regulations and have staff in-service training regarding regulations. Plan of correction of steps facility will take to ensure staff will provide the care and supervision to meet clients’ needs by due date.

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Based on an incident that occurred with S1 punched C1 in the face resulting in a black eye which poses an immediate risk to residents in care.
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Documentation of rooster of staff attendance in-service training shall be submitted to department by 2/7/23.


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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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Mai Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2023


LIC809 (FAS) - (06/04)
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