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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565801748
Report Date: 05/28/2024
Date Signed: 05/28/2024 02:02:14 PM

Unsubstantiated


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
05/21/2024 and conducted by Evaluator Kelly Dulek
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20240521131700
FACILITY NAME:SAILS LA LOMAFACILITY NUMBER:
565801748
ADMINISTRATOR:JAMIE CHAVEZ CALLEJASFACILITY TYPE:
735
ADDRESS:2065 ERBES RDTELEPHONE:
(805) 864-3733
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91362
CAPACITY:4CENSUS: 4DATE:
05/28/2024
UNANNOUNCEDTIME BEGAN:
12:17 PM
MET WITH:Jamie Chavez CallejasTIME COMPLETED:
02:10 PM
ALLEGATION(S):
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Client sustained unexplained injuries while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced initial complaint inspection at the facility today. Also present during today's visit were Quality Assurance Specialists (QAs) Liz Aced-Arnett and Patrick Brown from Tri-Counties Regional Center. The LPA arrived at 12:17 PM and met with Administrator Jamie Chavez Callejas. Entrance interview conducted.

During today's visit, LPA and QAs conducted a tour at 12:23PM, an interview with Administrator at 12:37PM, staff at 01:19PM, and reviewed and obtained copies of pertinent documents. The following was then determined:

Interview revealed that on 05/15/2024, facility staff noticed swelling and a small rash on Client #1 (C1)'s right eye. Staff then scheduled C1 for a doctor's visit the following day, where C1 was diagnosed with acne and rash and submitted a referral for dermatology. Later that evening, C1 had a seizure and following the
Report Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
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 2
Control Number 29-AS-20240521131700
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: 05/28/2024
NARRATIVE
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seizure, staff took C1 to the hospital for treatment. Staff interviewed indicated that while at the hospital following the seizure, C1's eye was still swollen, but did not appear bruised at that time. By Friday 05/17/2024, staff observed C1's eye to have yellow/purple color bruising, which was noted in C1's daily care reports. Interview revealed that over that weekend 05/18-05/19/2024, the yellow color dissipated and no longer appears to have any bruising. A referral for dermatology is still pending at this time. Staff took photographs of C1's eye with both the swelling and the subsequent bruising and plan address this change during the dermatology visit. Staff interviewed indicated staff are present with C1 at all times and at no time did C1 sustain an injury at the facility that staff are aware of. Based on interview and record review, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation that "client sustained unexplained injuries while in care" is deemed UNSUBSTANTIATED at this time.

No citations issued. Exit interview conducted. A copy of today's report was provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2