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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607799
Report Date: 04/30/2024
Date Signed: 04/30/2024 01:43:50 PM

Document Has Been Signed on 04/30/2024 01:43 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:SAILS SIMIFACILITY NUMBER:
197607799
ADMINISTRATOR/
DIRECTOR:		MARCHELINO ROOSFACILITY TYPE:
735
ADDRESS:3311 TAPO CANYON RDTELEPHONE:
(805) 387-2616
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY: 4CENSUS: 4DATE:
04/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Marchelino RoosTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Brian Balisi arrived unannounced to conduct a one year required annual. Upon arrival, the LPA met with staff and explained the reason for the visit.  The Administrator, Marchelino Roos arrived shortly after.

At approx 9:45am, the LPA along with the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. One (1) client was in the home while the other three (3) were at Day programs.

Kitchen: The kitchen area was observed at approx 10:00 a.m.  The facility has a sufficient supply of non-perishable and perishable food items properly stored. Knives and sharps are stored in a locked closet adjacent to the kitchen.

Common areas:  Living and dining room furniture were observed to be in good condition. Smoke detector(s) and carbon monoxide detector were tested and were operational at the time of the visit. The LPA observed required postings throughout the common space. The fire extinguisher was charged and serviced on 01/16/2024

Garage/Outdoor: The washer and dryer are in the garage. Cleaning supplies and disinfectants are stored in a locked cabinet inaccessible to clients. Facility files are in a file cabinet. The backyard has a covered outdoor area equipped with furniture for client use. The side gate was self-closing and latched. No bodies of water noted at the time of visit.

Restrooms: The client restrooms were clean, sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with soap and paper towels. The hot water temperature was measured and in compliance between 105- and 120-degrees Fahrenheit at the time of the visit.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE: DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/30/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/30/2024
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Continued from 809

Bedrooms: There are four (4) client rooms, which were furnished with appropriate linens and required furniture. Adequate lighting in all bedrooms was observed.

Records review began at approx 11am:  The LPA reviewed four (4) client files for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. The LPA reviewed six (6) staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, and current first aid certification. All files were observed to be complete at the time of the visit. The facility is vendored by Tri-Counties Regional Center (TCRC) as a level 4-i home. The last disaster drill was conducted on 04/29/2024.

Medications: Medications review began at approx 11:45 a.m.; medications are centrally stored and locked in a closet adjacent to the kitchen. Medications are labeled and checked for expiration dates. No errors observed during the medication review.

The LPA obtained the following documents: LIC500 Personnel Report, LIC9020 Client Roster, staff schedule, surety bond, and liability insurance.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024
LIC809 (FAS) - (06/04)
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