197607799-4-21-2023-29-AS-MARO-CR4SBL-20230421134407

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607799
Report Date: 04/21/2023
Date Signed: 04/21/2023 01:44:44 PM

Document Has Been Signed on 04/21/2023 01:44 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 SIMI		FACILITY NUMBER:	197607799
ADMINISTRATOR:	MARCHELINO ROOS		FACILITY TYPE:	735
ADDRESS:	3311 TAPO CANYON RD		TELEPHONE:	(805) 387-2616
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY: 4		CENSUS: 4	DATE:	04/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Marchelino Roos		TIME COMPLETED:	02:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Martha Arroyo arrived unannounced to conduct a one year required annual. The last annual conducted at this facility was on 05/25/2022. Upon arrival, the LPA was greeted at the door by staff Maggie. The Administrator, Marchelino Roos arrived shortly after and the reason for the visit was explained. Entrance interview conducted.

At 9:40am, the LPA along with the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Kitchen: The kitchen area was observed at 9:40 a.m. The facility has a sufficient supply of non-perishable and perishable food items. Knives and sharps are stored in a locked closet adjacent to the kitchen.

Common areas: Living and dining room furniture were observed to be in good condition. At 9:47 a.m., smoke detector(s) and carbon monoxide detector were tested and were operational at the time of the visit. The LPA observed required postings throughout the common space. The fire extinguisher was charged and serviced on 01/24/2023.

Garage/Outdoor: The washer and dryer are in the garage. Cleaning supplies and disinfectants are stored in a locked cabinet inaccessible to clients. Facility files are in a file cabinet. The backyard has a covered outdoor area equipped with furniture for client use. The side gate was self-closing and latched. No bodies of water noted at the time of visit.

Restrooms: The two client restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with soap and paper towels. The hot water temperature was measured and in compliance between 105- and 120-degrees Fahrenheit at the time of the visit.

Report Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023

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: 04/21/2023

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Report Continued from LIC 809...

Bedrooms: There are five (5) client rooms, which were furnished with appropriate linens and required furniture. Adequate lighting in all bedrooms was observed.

Records: The LPA reviewed client records at 10:00 a.m. and staff records at 11:10 a.m. The LPA reviewed four (4) client files for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. The LPA reviewed two (2) staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, and current first aid certification. All files were complete. The LPA also audited the current Administrator’s file and it was in order. The facility is vendored by Tri-Counties Regional Center (TCRC) as a level 4-i home. The last disaster drill was conducted on 03/27/2023. The LPA obtained the following documents: LIC500 Personnel Report, LIC9020 Client Roster, staff schedule, surety bond, and liability insurance.

Medications: Medications review began at 10:44 a.m.; medications are centrally stored and locked in a closet adjacent to the kitchen. Medications are labeled and checked for expiration dates. The LPA advised the Administrator to ensure that all the necessary information is properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023

LIC809 (FAS) - (06/04)

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