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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157806038
Report Date: 10/15/2025
Date Signed: 10/16/2025 04:44:10 PM

Document Has Been Signed on 10/16/2025 04:44 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
MONTEREY PARK CRP RO, 1000 CORPORATE CNTR DR. #200A
MONTEREY PARK, CA 91754
FACILITY NAME:SAILS WESTBROOK CRISISFACILITY NUMBER:
157806038
ADMINISTRATOR/
DIRECTOR:		EMILIO SAUCEDOFACILITY TYPE:
730
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 2CENSUS: 2DATE:
10/15/2025
TYPE OF VISIT:Annual/RequiredUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Administrator, Emilio SaucedoTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On October 15, 2025, at 10:15AM, Licensing Program Analysts (LPAs) Amber Hunter and Humberto Flores, conducted an unannounced Annual Inspection at Sails Westbrook Crisis Group Home (GH) and met with Administrator Emilio Saucedo. The LPAs stated the purpose of the inspection to the GH representatives.

The LPAs conducted a tour of the facility along with House Manager (HM) Bianca Chiquetes. It was observed that the facility was clean, safe, sanitary and in good repair. The passageways and ramps are unobstructed. The disinfectants and cleaning solutions are inaccessible to the children. There are no swimming pools or similar bodies of water in the facility. The children in care are always supervised and protected. The GH representative stated that there are no firearms in the facility. The temperature in the rooms that clients occupy are maintained between 68 and 85 degrees (F) and the hot water temperature was at 105.4F. The GH maintains supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days; nutritious snacks are provided between meals. Medications are locked and accessible only to employees supervising stored medications. A medication count was conducted, and it was correct. The fire alarms and carbon monoxide detectors were checked and are operating. The GH serves developmental disable clients between the ages 12-17, ambulatory and non-ambulatory.
NAME OF LICENSING PROGRAM MANAGER: Jean Herring
NAME OF LICENSING PROGRAM ANALYST: Humberto Flores
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 10/16/2025 04:44 PM - It Cannot Be Edited


Created By: Humberto Flores On 10/15/2025 at 04:15 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
, 1000 CORPORATE CNTR DR. #200A
MONTEREY PARK, CA 91754

FACILITY NAME: SAILS WESTBROOK CRISIS
FACILITY NUMBER: 157806038

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
84361(f)
(f) The licensee must maintain a monthly log of each use of manual restraints. The log must include:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the LPAs observed that the GH did not maintain a monthly log of each use of manual restraint, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2025
Plan of Correction
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The GH will submit to the licensing agency a copy of the monthly log of manual restraints.
Section Cited
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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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.
Jean Herring
NAME OF LICENSING PROGRAM MANAGER:
Humberto Flores
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2025


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CRP RO, 1000 CORPORATE CNTR DR. #200A
MONTEREY PARK, CA 91754
FACILITY NAME: SAILS WESTBROOK CRISIS
FACILITY NUMBER: 157806038
VISIT DATE: 10/15/2025
NARRATIVE
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cont.#2

Children Records:
The LPAs reviewed 1 children's file. The files contain record of client’s medical assessment, admission agreement , consent forms, weight record, emergency information, appraisal and needs and services plan, immunization record, tuberculosis test, centrally stored medication record, safeguards for property/valuables, personal rights form and cash resource information.

Staff Records:
The LPAs reviewed 2 employees’ file. The files contain the following documentation: first aid certificate, Child Abuse Index Checks/Department of Justice (DOJ)/Federal Bureau of Investigation (FBI) criminal record clearances, education verification, personnel record, health screening, criminal record statement, employee rights and tuberculosis test. Personnel policies, job descriptions and training verification are included in the employees’ files. A verification of criminal record clearances was conducted for all the staff listed on the LIC500. All the employees in the LIC500 are cleared with Child Abuse Index Checks/Department of Justice (DOJ)/Federal Bureau of Investigation (FBI).

Administration/Accountability:
The minutes of board of directors' meetings were available to the licensing agency to inspect, audit, and copy upon demand. The Emergency Evacuation plan and physical plant sketches are posted. The Emergency Disaster Plan, LIC 610C was posted. Personal rights listing is posted. Facility License was posted in a prominent place.

The GH did not maintain a monthly restraint log. This is a violation of California Code of Regulations, Title 22, Division 6, Section 84361(f):
(f) The licensee must maintain a monthly log of each use of manual restraints
NAME OF LICENSING PROGRAM MANAGER: Jean Herring
NAME OF LICENSING PROGRAM ANALYST: Humberto Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CRP RO, 1000 CORPORATE CNTR DR. #200A
MONTEREY PARK, CA 91754
FACILITY NAME: SAILS WESTBROOK CRISIS
FACILITY NUMBER: 157806038
VISIT DATE: 10/15/2025
NARRATIVE
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cont.#3

A citation type B was issued.

A copy of this report, citation page, LIC811s and appeal rights were provided to the facility. Appeal rights were explained.

Exit interview conducted.
NAME OF LICENSING PROGRAM MANAGER: Jean Herring
NAME OF LICENSING PROGRAM ANALYST: Humberto Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025
LIC809 (FAS) - (06/04)
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