565802405-8-25-2025-29-AS-KBUY-DKYJ2H-20250828063954

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802405
Report Date: 08/25/2025
Date Signed: 08/25/2025 03:02:44 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
08/08/2025 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 29-AS-20250808102626

FACILITY NAME:	SAILS 50/50		FACILITY NUMBER:	565802405
ADMINISTRATOR:	DANIKA-JEAN LEWIS		FACILITY TYPE:	735
ADDRESS:	1071 BALSAMO AVE		TELEPHONE:	(760) 631-7550
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY:	4	CENSUS: 4	DATE:	08/25/2025
		UNANNOUNCED	TIME BEGAN:	10:05 AM
MET WITH:	Danika-Jean Lewis		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff does not provide adequate supervision to resident.

Staff does not ensure a safe environment to resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent unannounced complaint visit to continue the investigation on the allegations above. Upon arrival LPA met with Administrator Danika-Jean Lewis and explained the reason for the visit.

On 08/13/2025, from 10:02 a.m. to 03:00 p.m., LPA initiated the 10 day-day complaint visit. LPA conducted physical plant, interviewed staff and reviewed and obtained copies of pertinent documents relevant to the investigation. Today LPA conducted physical plant, interviewed staff and reviewed and obtained copies of additional pertinent documents relevant to the investigation.

It was reported that "Staff does not provide adequate supervision to resident" and "Staff does not ensure a safe environment to resident" as it was alleged that due to leadership change and unwarranted changes in medication there have been in increase in property destruction and resident behaviors.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2025

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-20250808102626

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: 08/25/2025

NARRATIVE

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LPA’s records review of incident reports revealed the following incident reports were received and reviewed by the Regional Office. 08/05/2025 at approx 8pm, Resident #1 (R1) entered Resident #2 (R2)s bedroom, attempted to push R2 out of R2's bed. Four (4) staff intervened and relocated R2 out R2's bedroom. After R2 was relocated R1, exited the room and returned to R1's room on their own accord. Staff conducted a wellness check and observed R1 laying in bed. Staff reminded R1 not to enter any roommates room without permission. There were no reported incident for the rest of the evening.

On 08/04 - R1 had a behavior which resulted, property destruction in R2's room, On 07/31, R1 had a behavior which resulted, property destruction in R2's room, on 07/28, R1 had a crisis event, which resulted in property destruction of patio furniture and a garbage can, On 07/27, R1 had a behavior which resulted in R1 striking another resident, On 07/25, R1 had a behavior which resulted in property destruction in bathroom, On 07/22, R1 threw a staff member’s phone outside of car window, which resulted in the phone being destroyed in oncoming traffic, on 07/14, R1 had a behavior which resulted in property destruction in the kitchen, On 07/13, R1 had a behavior which resulted in property destruction, On 07/09, R1 had a behavior which resulted in R1 striking another resident and property destruction in R2’s room.

Interviews conducted and records review revealed since December 2024, staff have observed in increased of incidents documented from February 2025 through July 2025. R1’s behaviors have been attributed to multiple factors, including R1’s hypersensitivity to environmental stimuli, limited communication abilities, interpersonal tensions with R2 and system-wide operational changes such as staff turnover and administrative change. As a result the facility has responded with weekly staff training's that cover de-escalation, sensory trigger management, positive reinforcement and structured engagement. The facility has also modified R1’s bedroom so that the doorway faces the living room instead of directly facing R2’s room to minimize accessibility into R2’s room. In the past Staff had sat in the hallway to monitor R1 and redirect R1 when they start walking toward R2’s room, however once R1 is in the middle of a behavior they can be difficult to redirect often knocking staff over or striking them in the process. Staff also conduct 15-minute checks, but due to the nature of R1’s behaviors, it’s not always sufficient to prevent incidents. R1 tends to ruminate on issues for days and sometimes reacts to events long after they occur. R1 may express frustration or act out late at night, which makes behavioral tracking more complex. R2 also refuses to close or lock their door. When staff attempt to close it, R2 resists and becomes combative.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2025

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20250808102626

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: 08/25/2025

NARRATIVE

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This behavior can escalate tensions between R2 and R1. R2 does not want anyone near R2’s doorway or inside their room, which presents complications for staff who are trying to ensure safety for both residents. These observations have resulted in R1’s Behavioral Plan dated August 6, 2025 to be updated to support crisis-level interventions. Prior to Danika becoming the Administrator , the psychiatric follow-up was only occurring once per year. Currently, R1 is seen every two weeks and Psychotropic medications are now being regularly re-evaluated.

In addition, LPA’s interview with Redwood District Manager Joanna Iniguez and Administrator Danika-Jean Lewis revealed, R1’s medications were adjusted and Danika started working close with R1. Danika actively engaged R1 in daily activities. At that time, none of their residents were attending a day program due to behavioral concerns. This resulted in the facility discussing medications that could help decrease the severity of behaviors. The facility is currently working on decreasing certain medications while continuing to monitor behaviors. There has been a noticeable increase in behavioral incidents, but efforts are ongoing to manage them proactively. As of today, Resident #3 (R3) attend a day program, with Resident #4 (R4) and R2 getting evaluated to attend a program next week. Changes to R1’s medications were made based on recommendations from the psychiatrist and behavioral team. Historically, the previous administration had reported only minor behaviors, but currently all behaviors are being documented thoroughly in incident reports, which may be the reason for the uptick in incident reports. For now, Staff are focusing on regulation strategies, helping R1 re-regulate when signs of distress appear. R1 is walking around more, which seems to help. R1 is highly sensitive to loud noises, so staff try to reduce environmental stimulation when possible. Staff are continuing to adjust the behavioral plan in collaboration with the BCBA and medical team. There is an ongoing effort to evaluate triggers, increase coping mechanisms, and maintain safety. The facility has demonstrated awareness of R1’s needs and has taken numerous steps to address both supervision and environmental safety concerns. Measures include increased psychiatric oversight, staff training, individualized behavioral planning, and consistent documentation. Despite the complexity of R1 and other residents needs, the facility is actively working to manage behaviors, ensure safety, and maintain a supportive environment. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations "Staff does not provide adequate supervision to resident" and "Staff does not ensure a safe environment to resident" are deemed Unsubstantiated at this time.
Exit interview conducted and copy of report issued.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2025

LIC9099 (FAS) - (06/04)

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