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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607799
Report Date: 08/23/2024
Date Signed: 08/23/2024 03:27:02 PM

Document Has Been Signed on 08/23/2024 03:27 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: 3DATE:
08/23/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Marchelino RoosTIME VISIT/
INSPECTION COMPLETED:
03:35 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Martha Arroyo and Erica Mosley conducted an unannounced Case Management – Incident visit at 1:00 PM for the purpose of investigating a self-reported incident report. The Administrator Marchelino Roos arrived at the facility at approximately 1:15 p.m. and at this time the reason for the visit was explained. Entrance interview conducted.

On 08/18/2024, the Department received an incident report stating that on 08/16/2024, at approximately 11:31 p.m., the Administrator received a call from staff reporting that upon their arrival, they found three (3) residents unsupervised. The Administrator, who was nearby drove to the facility to investigate. During staff interview, Staff #1 (S1) stated that they took Resident #1 (R1) out for a walk to a 7-eleven store because R1 wanted to purchase some snacks. They left Staff #2 (S2) in charge of supervising the other three (3) residents who were sleeping at the time. However, Staff #3 (S3), who arrived early, found the three (3) residents unsupervised, with no staff present in the house. At approximately 11:48 p.m., the Administrator contacted S2 to hear their version of the events and subsequently placed S2 on verbal administrative leave to conduct a further investigation into the potential neglect of residents.

During today’s visit, LPAs conducted interviews with the Administrator and one (1) staff member between 1:20 p.m. and 2:35 p.m., conducted a file review at 1:45 PM, and obtained copies of pertinent documents relevant to the investigation.

Report Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2024
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: 08/23/2024
NARRATIVE
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Report Continued from LIC 809...

Records reviewed and interviews conducted revealed that the facility had two (2) staff scheduled to work the evening shift of 4:00 p.m. to 12:00 a.m. and two (2) staff scheduled to work the nocturnal shift of 12:00 a.m. to 8:00 a.m. Interviews conducted revealed that R1 was getting ready to leave the facility through the back door. S2 advised S1 to take R1 to the store nearby to get snacks. S1 left the facility after R1 to accompany them to the store at approximately 11:15 p.m. Further interviews conducted revealed that S3 arrived about 30 minutes early to their shift which started at 12:00 a.m. At this time, S3 noticed that there was no other staff in the facility and called the Administrator at about 11:31 p.m. The Administrator along with S1 and R1 arrived at the facility at approximately 11:36 p.m. and met with S3. At this time, it was noted that the three (3) residents were left alone as S2 was nowhere near the site. Based on the information obtained and reviewed, the Department has enough evidence to say S2 left the facility before their shift ended at 12:00 a.m. leaving three (3) residents unsupervised and unattended for approximately 15 minutes 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. An additional $500 civil penalty is also being assessed as this is a repeat violation from 01/05/2024. Total civil penalty amount assessed today is $1,000.



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

DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/23/2024 03:27 PM - It Cannot Be Edited


Created By: Martha Arroyo On 08/23/2024 at 03:04 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SAILS SIMI
FACILITY NUMBER: 197607799

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/23/2024
Section Cited
CCR
85065.6(c)

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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:
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The Licensee stated they will conduct an in-house training that includes supervision, policy, procedures, and clients rights and submit proof to CCL no later than 08/30/2024.
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Based on record review and interviews conducted, the licensee did not comply with the section cited above as S2 left the premises before their shift ended leaving three (3) residents unsupervised, which posed an immediate health, safety, or personal rights risk to persons in care.
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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.
Additional $500 due to this being a repeat violation from 01/05/2024. Total amount being assesed today is $1,000.

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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.
SUPERVISOR'S NAME:Desaree Perera
LICENSING EVALUATOR NAME:Martha Arroyo
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2024


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