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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607799
Report Date: 10/22/2021
Date Signed: 10/22/2021 11:24:55 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/02/2021 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20210902112851
FACILITY NAME:SAILS SIMIFACILITY NUMBER:
197607799
ADMINISTRATOR:AYOBAMI TEMILOLUWAFACILITY TYPE:
735
ADDRESS:3311 TAPO CANYON RDTELEPHONE:
(818) 224-7222
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY:4CENSUS: 3DATE:
10/22/2021
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Omolara Owoyemi TIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Client sustained injuries due to lack of care and supervision

Facility did not obtain timely medical treatment for client
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint investigation for the above allegations. Upon arrival LPA met with Omolara Owoyemi and explained the reason for the visit. LPA called Administrator Ayobami who stated that Omolara can sign in his place.

During the course of the investigation, LPA conducted a physical plant tour 09/09/2021 as well as interviewed Administrator, staff and residents. LPA also gathered and reviewed facility documentation pertinent to the allegations. LPA also interviewed parties with knowledge of the situation.
It was alleged that Due to lack of supervision Resident 1 (R1) sustained Injuries while in care, LPA's interview with R1 revealed that R1 routinely takes walks around the backyard while a staff member supervises R1 from inside the home sitting on a couch next to the sliding door. The day R1 sustained injuries , R1 stated they tripped over a hose in the backyard. They immediately got themselves up and walked over to Staff 1 (S1) for medical attention.
(Continued on 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021
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 4
Control Number 29-AS-20210902112851
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: SAILS SIMI
FACILITY NUMBER: 197607799
VISIT DATE: 10/22/2021
NARRATIVE
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(Continued from 9099)

LPA interview with S1 revealed they were standing by the sliding door when R1 was walking around the backyard.   S1 stated they did not witness the fall, as R1 fell just beyond S1's view. LPA records review revealed a sufficient number of staff scheduled to meet the needs of their residents on the day of the incident. Based on the information gathered during this and previous visits, the department does not have sufficient evidence to determine that due to lack of supervision R1 sustained injuries while in care.   Therefore, this allegation has been UNSUBSTANTIATED at this time.


It was alleged that Facility did not obtain timely medical treatment for client. LPA interview with R1 revealed that S1 conducted first aid to R1, which included cleaning the wounds with cotton balls, applying ointment and bandages. R1 stated that S1 asked if R1 wanted to go to the hospital, but R1 refused to go. Interview with S1 revealed that S1 informed R1 they were going to call 911 so R1 can go to the hospital, but R1 refused because R1 stated they felt fine at that time and did not want to go to the hospital. The next day, R1 stated,  Staff 2 (S2) arrived to the facility in the morning,  observed R1's injuries and scheduled a hospital visit. LPA interview with S2 revealed on the day that R1 sustained their injuries, S1 called S2 and informed S2 that R1 fell and S1 administered some first aid, and R1 did not want to go to the hospital. S2 informed S1 they will observe injuries in the morning when they arrive to the facility. S2 stated when they arrived to the facility in the morning they observed the injuries were beginning to bruise so they scheduled a hospital visit for the same day. Based on the information gathered during this and previous visits, the department does not have sufficient evidence to determine that facility did not obtain timely medical treatment for client.  Therefore, this allegation has been UNSUBSTANTIATED at this time.

Exit interview conducted. Report issued and sent via email.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/02/2021 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20210902112851

FACILITY NAME:SAILS SIMIFACILITY NUMBER:
197607799
ADMINISTRATOR:AYOBAMI TEMILOLUWAFACILITY TYPE:
735
ADDRESS:3311 TAPO CANYON RDTELEPHONE:
(818) 224-7222
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY:4CENSUS: 3DATE:
10/22/2021
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Omolara Owoyemi TIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
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9
Facility did not notify client's representative of incidents affecting client's health.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint investigation for the above allegation. Upon arrival Upon arrival LPA met with Omolara Owoyemi and explained the reason for the visit. LPA called Administrator Ayobami who stated that Omolara can sign in his place.During the course of the investigation, LPA conducted a physical plant tour 09/09/2021 as well as interviewed Administrator, staff and residents. LPA also gathered and reviewed facility documentation pertinent to the allegations. LPA also interviewed parties with knowledge of the situation. It was alleged that Facility did not notify client's representative of incidents affecting clients health. LPA interview with R1, Administrator and staff revealed that R1's responsible party was not informed of the incident until the next day. LPA records review revealed no confirmation that Resident 1's (R1s) resonsible party was informed of incident in a timely manner. Based on information gathered during this and previous visits the allegation that Facility did not notify client's representative of incidents affecting clients health is deemed SUBSTANTIATED at this time.
Pursuant to CCR, Title 22, Division 6, Chapter 8, the following deficiencies are cited (Refer to LIC 9099-D).
Exit Interview conducted/ Citations issued / Appeal Rights Discussed / A Copy of Report Issued
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 29-AS-20210902112851
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SAILS SIMI
FACILITY NUMBER: 197607799
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/05/2021
Section Cited
CCR
85072(3)
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85072(3) Person Rights - To have communications to the facility from his/her relatives or authorized representative answered promptly and completely.

This requirement was not met as evidenced by:
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Administrator agreed to review section 85072(3) with administrative and support staff and will provide LPA via E-mail, with documentation that a meeting was held and regulation reviewed by end of business day 11/5/2021.
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Based on LPAs record review, interviews with resident, staff, and parties with knowledge of the situation the facility failed to provide timely communication to R1's responsible party in regards to health related incidents which poses as a potential health and safety 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: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4