565802405-9-12-2024-29-AS-DPEA-D9LTEL-20240930144006

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802405
Report Date: 09/12/2024
Date Signed: 09/12/2024 03:27:23 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
07/18/2024 and conducted by Evaluator Martha Arroyo

COMPLAINT CONTROL NUMBER: 29-AS-20240718144444

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: 4	DATE:	09/12/2024
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Marchelino Roos		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff member punched resident multiple times.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegation. LPA M. Arroyo conducted an initial complaint visit on 07/24/2024, and a subsequent visit on 08/13/2024 joined by Tri-Counties Regional Center (TCRC) Quality Assurance Specialist (QAS) Ryan Landseadel and Patrick Brown. On today's visit, LPA Arroyo met with Administrator, Marchelino Roos. Entrance interview.

During the initial visit on 07/24/2024, LPA Arroyo along with staff conducted a plant tour to ensure there were no health and safety concerns, conducted an interview with the Administrator at 9:25 a.m., conducted a resident file review starting at 9:12 a.m., and obtained copies of pertinent documents. On 08/13/2024, LPA Arroyo and QAS conducted interviews with the Administrator and three (3) staff members between 9:27am – 10:30am. Police Report was also obtained and reviewed.

Report Continued on LIC 9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

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-20240718144444

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: 09/12/2024

NARRATIVE

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Report Continued from LIC 9099...

It was alleged that staff member punched resident multiple times. It was reported that Resident #1 (R1) was acting out while in the car and inside the store resulting in Staff #1 (S1) punching R1 several times. Information obtained during the course of the investigation revealed R1 was admitted to the facility on 11/26/2021; and R1’s physicians report, dated 05/05/2023, listed R1’s primary diagnosis as autism spectrum disorder with a secondary diagnosis as intellectual disability and aggressive behaviors since 02/09/2022. And although R1 was identified as frequently confused, R1 is able to follow instructions and is able to communicate needs occasionally. Records review and interviews conducted revealed that R1 is non-verbal and exhibits a range of behaviors including aggression and self-injury. Additionally, R1 often bangs their head during episodes and may engage in other forms of self-injury or aggression, such as ripping their clothes or trying to drop staff to the floor. Staff stated that R1’s behavior can be unpredictable at times but tend to happen when R1 demands things but are not given or when being re-directed. Further record review and interviews conducted revealed that R1 has had a 1:1 staff to ensure the safety of both R1 and the other residents residing in the home. Interviews conducted with staff revealed that S1 showed a strong ability to handle clients effectively, addressing their needs appropriately and managing their behavior well. Additionally, throughout interactions with clients, S1 maintained their composure. They never lost their patience, temper, or raised their voice, even in challenging situations and de-escalated clients during behavior episodes. Furthermore, police report dated 07/17/2024, noted that a small scratch was observed on S1’s right hand; however, R1 did not have any visible injuries upon law enforcement observation. Although the allegations may have happened or is valid, there is insufficient evidence to prove the alleged violation occurred, therefore this allegation is deemed Unsubstantiated at this time.

No citations issued at this time. Exit interview conducted. Report was reviewed and a copy was issued.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

LIC9099 (FAS) - (06/04)

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