<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607799
Report Date: 01/29/2025
Date Signed: 01/29/2025 03:58:25 PM

Document Has Been Signed on 01/29/2025 03:58 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:
01/29/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Cecilia MendezTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA), Martha Arroyo conducted an unannounced Case Management – Incident visit for the purpose of investigating a self-reported incident report and SOC 341. Upon arrival, there were two staff and two residents present. Staff contacted the District Manager (DM), Joanna Iniguez via telephone and at this time the reason for the visit was explained. Entrance interview.

On 01/23/2025, the Department received an incident report stating that on 01/21/2025, at approximately 2:30 p.m., Resident #1 (R1) was sitting in the dining room when suddenly Resident #2 (R2) punched R1 in the head multiple times. R1 attempted to back away and began to cry. The staff nearby immediately intervened, positioning themselves between both residents and redirecting R1 away from R2 to de-escalate the situation. Following the incident, R1 was assisted to their room assessed by staff for any injuries. No visible injuries were observed at the time, but R1 complained of a headache. R1 was taken to Adventist Health Simi Valley for professional evaluation. At the hospital, R1 was examined by a physician who confirmed there were no serious head injuries. R1 was provided medication for pain and nausea with home care instructions to monitor for any changing conditions and nausea medication as needed.

During today’s visit, beginning at 3:14 p.m., the LPA conducted a telephonic interview with the DM, conducted interviews with three residents between 3:25 p.m. and at 3:50 p.m., and reviewed and obtained copies of pertinent documentation relevant to the investigation.

The LPA has determined further investigation is needed and will return at a later date to complete the investigation if warranted. No immediate or potential health and safety concerns noted at this time.



Exit interview conducted and copy of report issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1