197607799-5-24-2022-29-AS-BBAI-CEQPZ9-20220524114511

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607799
Report Date: 05/24/2022
Date Signed: 05/24/2022 11:46:23 AM

Document Has Been Signed on 05/24/2022 11:46 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 SIMI		FACILITY NUMBER:	197607799
ADMINISTRATOR:	AYOBAMI TEMILOLUWA		FACILITY TYPE:	735
ADDRESS:	3311 TAPO CANYON RD		TELEPHONE:	(818) 224-7222
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY: 4		CENSUS: 4	DATE:	05/24/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Marchelino Roos - Administrator		TIME COMPLETED:	12:00 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) Brian Balisi arrived to this facility today to conduct a One (1) year Required inspection of this facility with emphasis on infection control practices and procedures. LPA met with Marchelino Roos and explained the reason for the visit. There are (4) clients in care with (2) clients attending a day program. The kitchen appeared to be clean at this time and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of perishable and non-perishable food at the facility; properly stored. Sharp objects were observed stored in a locked pantry closet to the left of the fridge. Pantry closet was observed to be inaccessible to clients at this time. No Cleaning supplies and toxins were observed in this area at this time. Fire extinguishers were observed to be fully charged and serviced. Next to the kitchen was a sitting area and dining table. Dining furniture in kitchen and dining room area appeared to be clean and sufficient at this time. At 10:05am, LPA observed (2) clients eating snacks at the table. The resident bedrooms were properly furnished with a bed, night stand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPA observed most bathrooms were clean, properly supplied and had functional fixtures. The hot water was measured in each bathroom between between 105 - 120 degrees Fahrenheit. At 10:15am LPA observed faucet for cold water in hallway bathroom not functioning at this time. LPA observed functional water fixtures located in bathroom in bedroom #1, hallway bathroom by entry , and kitchen sink.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022

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: 05/24/2022

NARRATIVE

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Continued from 809-C

Common Areas: These included the living room, seating area and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. Planned activities and games were stored on top of the counter near the microwave. Dining room furniture appeared to be relatively clean and functional at this time.

Outdoor Area: There was a shaded area with sufficient room for activities. LPA observed sufficient furniture designated for outdoor use. There are no bodies of water on the premises. Garage was accessible from the exterior and the kitchen. LPA observed garage area locked to residents at the time of visit. Garage is used as storage /office and laundry area. Cleaning supplies were observed locked in a black cabinet in this area. LPA observed a sufficient supply of PPE in this area as well. . LPA did not observe any obstructions to emergency exits.

The LPA spoke with Marchelino regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate the master bedroom as a single isolation room if the facility has a confirmed case of COVID-19. COVID-19 testing is conducted weekly if anyone shows any symptoms. The facility’s policies and procedures as it pertains to infection control are adequate at this time.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Exit interview conducted, appeal rights discussed, report issued and sent via email.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/24/2022 11:46 AM - It Cannot Be Edited

Created By: Brian Balisi On 05/24/2022 at 11:11 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: 05/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in hallway bathroom by bedroom #1 as the cold water faucet was observed not functioning at the time of visit, which poses a potential health and safety risk to persons in care.
	POC Due Date: 06/03/2022
	Plan of Correction
1 2 3 4	Administrator agreed to have faucet repaired by POC date and will send LPA a picture or video via email of cold water faucet functioning.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Brian Balisi

LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022

LIC809 (FAS) - (06/04)

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