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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607799
Report Date: 01/05/2024
Date Signed: 01/05/2024 11:12:12 AM

Document Has Been Signed on 01/05/2024 11:12 AM - 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:MARCHELINO ROOSFACILITY TYPE:
735
ADDRESS:3311 TAPO CANYON RDTELEPHONE:
(805) 387-2616
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY: 4CENSUS: 4DATE:
01/05/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Marchelino RoosTIME COMPLETED:
11:30 AM
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 was one staff and one client present. The Administrator, Marchelino Roos arrived shortly after and the reason for the visit was explained. Entrance interview.

On 12/27/2023, the Department received an incident report stating that on 12/26/2023 at approximately 12:47 a.m., the Administrator received a telephone call from management informing the Administrator that law enforcement was currently at the facility conducting a welfare check. This was in response to a call made to law enforcement from a resident claiming they were left unsupervised by Staff #1 (S1). At 1:20 a.m. when Administrator arrived at the facility, law enforcement had already left the premises. The Administrator proceeded to conduct interviews with the residents resulting in placing S1 on immediate verbal administrative leave to conduct further investigation. Further stated was that on 12/27/2023, a Quality Assurance (QA) designee conducted an internal investigation and it found that S1 had arrived at the facility at 12:00 a.m. but was not feeling well. At approximately 12:15 a.m., S1 had left the facility with the intention of obtaining medication since S1 was not feeling well resulting in leaving three residents unattended and unsupervised. However, after arriving to CVS, S1 found that it was closed and proceeded to drive to another CVS. Resident #1 (R1) and Resident #2 (R2) were awake and R1 called local law enforcement to notify them that they had been left alone at around 12:25 a.m.

On today’s visit, the LPA conducted a brief plant tour at 9:15 a.m., conducted an interview with the Administrator at 9:35 a.m., conducted a file review at 10:05 a.m., and obtained copied of pertinent documents.

(Report Continued on LIC 809C...)

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE: DATE: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/05/2024
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 3
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: 01/05/2024
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
26
27
28
29
30
31
32
(Report Continued from LIC 809...)

Interview conducted and records reviewed revealed that S1 left the facility on 01/26/2023 at around midnight for approximately one (1) hour. Residents called law enforcement to report there was no staff at the facility providing care and supervision; therefore, law enforcement went out to do a wellness check. Additionally, by the time the Administrator arrived at the facility, law enforcement had left and S1 had returned to the facility. Based on the information obtained and reviewed, the Department has enough evidence to say that S1 left the facility leaving three (3) residents unsupervised and unattended creating a safety hazard.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited during the visit. This deficiency resulted in an absence of supervision which is a zero-tolerance deficiency as per Health & Safety Code 1597.58 which states that an immediate Civil Penalty of $500 will be assessed at the time of the citation and an additional $100 per day until the deficiency is corrected.



Exit Interview conducted. Copy of report, and appeal rights provided.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 01/05/2024 11:12 AM - It Cannot Be Edited


Created By: Martha Arroyo On 01/05/2024 at 10:40 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SAILS SIMI

FACILITY NUMBER: 197607799

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 01/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/05/2024
Section Cited
CCR
85065.6(c)

1
2
3
4
5
6
7
85065.6(c) In facilities providing care and supervision for 15 or fewer clients, there shall be at least one person on call on the premises.

This requirement was not met as evidenced by:
1
2
3
4
5
6
7
The Licensee has agreed to conduct an in-house training that includes supervision, policy, procedures, clients rights,and mandated reporting and submit proof to CCL no later than 01/05/2024.

POC has been met.
8
9
10
11
12
13
14
Based on record review and interviews conducted, the licensee did not comply with the section cited above as the NOC staff left the premises leaving residents unsupervised, which poses an immediate health, safety, or personal rights risk to persons in care.
8
9
10
11
12
13
14
An immediate $500 civil penalty is being assed today for Absence of Supervision which is a zero-tolerance deficiency as per Health & Safety Code 1597.58.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Desaree Perera
LICENSING EVALUATOR NAME:Martha Arroyo
LICENSING EVALUATOR SIGNATURE:
DATE: 01/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2024


LIC809 (FAS) - (06/04)
Page: 3 of 3