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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607799
Report Date: 11/10/2022
Date Signed: 11/10/2022 10:55:21 AM

Substantiated


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
11/02/2022 and conducted by Evaluator Zabel Chochian
COMPLAINT CONTROL NUMBER: 29-AS-20221102153113
FACILITY NAME:SAILS SIMIFACILITY NUMBER:
197607799
ADMINISTRATOR:MARCHELINO ROOSFACILITY TYPE:
735
ADDRESS:3311 TAPO CANYON RDTELEPHONE:
(818) 224-7222
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY:4CENSUS: 4DATE:
11/10/2022
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:MARCHELINO ROOSTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Client eloped from the facility.
Client's Individualized Program Plan (IPP) not followed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Zabel Chochian conducted an unannounced complaint visit regarding above allegations.

On 11/02/22, Woodland Hills Adult & Senior Care Regional Office received information that Client #1 (C1) eloped from the facility and that Staff did not follow C1’s Individualized Program Plan (IPP).
LPA reviewed the 09/11/2022 incident report and Tri-Counties Regional Center (TCRC) Residential Facility Investigation Report/Corrective Action Plan issued on 10/24/2022.

Following is a summary of the investigation finding:

There was one staff supervising four (4) clients at the time C1 eloped from the facility on 09/11/2022 at 10am. Staff Lawal Adeyemi was the only staff scheduled from 8am until 2pm on 9/11/22. The Sails Simi staff was unable to follow the home's elopement policy by following C1 into the community because (cont..)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022
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 3
Control Number 29-AS-20221102153113
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: 11/10/2022
NARRATIVE
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 there was only one staff on duty supervising four (4) clients on 09/11/2022. C1 has a known history of elopement and is required to be supervised at all times while under the care of Sails Simi per C1’s Tri-Counties Regional Center (TCRC) Individualized Program Plan (IPP).

Per the home’s contract with TCRC, a minimum staffing ratio consistent with Title 17 is having one staff person whenever one resident is in the home and a second staff present whenever a second resident is in the home during awake hours.
The facility was understaffed on 9/11/22 from 8am-2pm and therefore could not follow C1 into the community when C1 eloped on 09/11/2022.

Based on the information gathered above, there is enough evidence to support the allegations above therefore, allegations are deemed Substantiated at this time.

The following deficiencies are cited per CA Code of Regulations, Title 22 (refer to LIC 9099D).
Exit interview conducted. A copy of the report and appeal rights provided.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20221102153113
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: 11/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/11/2022
Section Cited
CCR
80078(a)
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80078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs.

This requirement was not met as evidence by:
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Administrator provided schedule that indicates facility is staffed to meet clients needs. Administrator shall provide a written letter of understanding and following the approved Regional Center ratio for the facility..
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Based on record review and interviews, the facility did not have sufficient staffing on 9/11/2022 when C1 eloped from facility. Staff did not follow the approved Regional Center ratio.
This poses an immediate health and safety risk for 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: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3