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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565801748
Report Date: 08/17/2023
Date Signed: 08/17/2023 04:33:22 PM

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
08/01/2023 and conducted by Evaluator Sandra Urena
COMPLAINT CONTROL NUMBER: 29-AS-20230801144258
FACILITY NAME:SAILS LA LOMAFACILITY NUMBER:
565801748
ADMINISTRATOR:MARIA LASSITERFACILITY TYPE:
735
ADDRESS:2065 ERBES RDTELEPHONE:
(818) 676-9831
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91362
CAPACITY:4CENSUS: 4DATE:
08/17/2023
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Marchelino RoosTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff are not properly trained to manage clients' behaviors.

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sandra Urena conducted a subsequent visit to investigate the allegations listed above. The LPA arrived at 10:30 a.m., met with staff and explained the reason for the visit. Staff present stated that the administrator was not available. The LPA spoke with District Manager Joanna Iniguez on the phone and explained the reason for the visit. The LPA spoke with facility representatives, Nelson Rivera, Quality Assurance (QA) and Marchelino Roos, acting Administrator. The LPA conducted additional staff interviews between 11:07 a.m. and 12:45 p.m.
On 08/02/2023, Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced visit to investigate the allegations listed above. The LPA arrived at 10:30 a.m., met with staff and explained the reason for the visit. Staff present stated that the administrator was not available. The LPA tried to reach the District Manager Joanna Iniguez, but the call went to voicemail, and LPA left a message. LPA Urena conducted a collateral visit to the day program attended by R1.
Continues on LIC 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023
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 5
Control Number 29-AS-20230801144258
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 LA LOMA
FACILITY NUMBER: 565801748
VISIT DATE: 08/17/2023
NARRATIVE
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Staff are not properly trained to manage clients' behaviors.

On the allegation that Staff are not properly trained to manage clients' behaviors; it is the concern of the reporting party that facility staff are repeatedly requesting assistance from other agencies, and do not seem to have the appropriate techniques to address residents’ behaviors. To investigate the allegation, LPA Urena conducted staff interviews, and record review. The LPA reviewed the training records for the facility staff. The record review revealed that one out of two staff, had not received and had not filled out the facility’s New Participant Training Checklist (NPTC). The NPTC is designed to assist the new staff to become familiar with each resident in the facility and to address each residents’ individual needs. The S1 did not receive formal training by the facility administrators before starting to work with residents. The staff’s interviews revealed that one out two staff did not receive the appropriate training by the facility’s administration. Additionally, the staff’s interviews confirmed that although they have the experience to work with residents residing at the facility, the staff did not receive on-board training until two days after the initial day of employment at the facility.

Based on the information obtained through interviews and record review, there is sufficient evidence to support the allegation that staff are not properly trained to manage client’s behaviors. Therefore, the allegation is deemed Substantiated at this time.


The Pursuant to Title 22 of the CA Code of Regulations, and the Health and Safety Code, the following deficiency was cited (refer to LIC 809-D):

Citations were issued. Exit interview conducted with facility’s representative, today's report, and appeal rights were reviewed and issued.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20230801144258
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 LA LOMA
FACILITY NUMBER: 565801748
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/21/2023
Section Cited
CCR
80066(a)(6)
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Personnel Records. Each personnel record shall contain documentation of the educational background, training and/or experience for the type of facility where the employee works. This requirement is not met as evidenced by:
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The Administrator agreed to do the following:
1. Submit proof that staff received training to CCLD. Submit proof by 8/21/2023.
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Based on record review and interview, the licensee failed to ensure that staff received training, as staff files reviewed did not have any documented training, which poses a potential risk to clients 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: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
08/01/2023 and conducted by Evaluator Sandra Urena
COMPLAINT CONTROL NUMBER: 29-AS-20230801144258

FACILITY NAME:SAILS LA LOMAFACILITY NUMBER:
565801748
ADMINISTRATOR:MARIA LASSITERFACILITY TYPE:
735
ADDRESS:2065 ERBES RDTELEPHONE:
(818) 676-9831
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91362
CAPACITY:4CENSUS: 4DATE:
08/17/2023
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Marchelino RoosTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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2
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5
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9
Staff are not providing clients with proper grooming assistance.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sandra Urena conducted a subsequent visit to investigate the allegations listed above. The LPA arrived at 10:30 a.m., met with staff and explained the reason for the visit. Staff present stated that the administrator was not available. The LPA spoke with District Manager Joanna Iniguez on the phone and explained the reason for the visit. The LPA spoke with facility representatives, Nelson Rivera, Quality Assurance (QA) and Marchelino Roos, acting Administrator. The LPA conducted additional staff interviews between 11:07 a.m. and 12:15 p.m.
On 08/02/2023, Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced visit to investigate the allegations listed above. The LPA arrived at 10:30 a.m., met with staff and explained the reason for the visit. Staff present stated that the administrator was not available. The LPA tried to reach the District Manager Joanna Iniguez, but the call went to voicemail, and LPA left a message. LPA Urena conducted a collateral visit to the day program attended by R1.
Continues on LIC 9099 AC...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20230801144258
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 LA LOMA
FACILITY NUMBER: 565801748
VISIT DATE: 08/17/2023
NARRATIVE
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Staff are not providing clients with proper grooming assistance.

On the allegation that Staff are not providing clients with proper grooming assistance; it is the concern of the reporting party that the residents may need assistance with grooming, because it was observed that residents have overgrown nails. On 08/02/2023, the LPA conducted a collateral visit to the day program to interview R1 and conducted a visual assessment of R1’s grooming during the visit. R1 was dressed in casual clothing, appeared to be well groomed and nails were short and clean. Additionally, the LPA spoke with the Day Program staff who work closely with R1 about R1's daily physical appearance, and grooming. The staff stated that R1 is one of the best-groomed clients they have in the day program, and that they have not noticed any decline in R1’s appearance, clothing or personal grooming.

Based on the information obtained through interviews, and on observation, there is not sufficient evidence to support the allegation that staff are not providing clients with proper grooming assistance. Therefore, the allegation is deemed Unsubstantiated at this time.

Exit interview conducted with facility’s representative. A copy of the report was issued.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5