565802405-6-13-2023-29-AS-JAPL-CSU24N-20230615170413

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802405
Report Date: 06/07/2023
Date Signed: 06/13/2023 10:07:14 AM

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
07/19/2022 and conducted by Evaluator Teresa Camara

COMPLAINT CONTROL NUMBER: 29-AS-20220719114352

FACILITY NAME:	SAILS 50/50		FACILITY NUMBER:	565802405
ADMINISTRATOR:	ROOS, MARCHELINO		FACILITY TYPE:	735
ADDRESS:	1071 BALSAMO AVE		TELEPHONE:	(760) 631-7550
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY:	4	CENSUS: 2	DATE:	06/07/2023
		UNANNOUNCED	TIME BEGAN:	03:22 PM
MET WITH:	Marchelino Roos		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Resident was physically attacked by another resident on more than one occasion.
Facility is not following reporting requirements.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint visit regarding the above noted allegations. LPA met with administrator Marchelino Roos and explained the reason for the visit.

On 7/21/2022, LPA conducted a brief facility tour at 10:01 a.m., at 10:03 a.m. LPA interviewed staff 1 (S1), at 10:16 a.m. LPA interviewed resident 1 (R1), and at 10:33 a.m. interviewed administrator and obtained pertinent documents. During today's visit LPA obtained additional records at 3:25 p.m.

(continued on 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220719114352

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 50/50	FACILITY NUMBER: 565802405
	VISIT DATE: 06/07/2023

NARRATIVE

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(continued from 9099)

Regarding the allegations:
Resident was physically attacked by another resident on more than one occasion.
Facility is not following reporting requirements.

In reviewing records for R1, it is noted that R1 has a history of self-injurious behaviors, property destruction and false allegations. The facility staff keep notes of R1 behaviors. There were two incidents reported to CCL; 6/19/2022 and 7/22/2022. During those incidents R1 invaded the personal space of resident 2 (R2) and R2 reacted by grabbing R1's shirt. There were no observed injuries in either incident.

During LPA's visit on 7/21/2022 LPA asked R1 to demonstrate how R2 pulled on their shirt. R1 pulled on the neckline of their shirt. When R1 pulled on their own shirt it left a red mark on R1's chest. R1 stated they have sensitive skin.

Other incidents in which there were no injuries and no contact with others are noted in R1's Intervention Plan records. Based on interviews and records reviewed, the above noted allegations are deemed Unsubstantiated at this time.

Exit interview conducted and a copy of the report issued to administrator.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2023

LIC9099 (FAS) - (06/04)

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