565802405-9-28-2021-29-AS-ASMH-C7AQKE-20210928121414

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565802405
Report Date: 09/28/2021
Date Signed: 09/28/2021 12:14:33 PM

Document Has Been Signed on 09/28/2021 12:14 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
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:	09/28/2021
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Carlos Marcia		TIME COMPLETED:	12:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) Ashley Smith, along with Tri-Counties Regional Center Quality Assurance Specialist Freddie Garcia, conducted an unannounced Case Management - Incident visit at 9:30 a.m. The LPA and QAS met with staff and explained the reason for the visit. Administrator Marchelino Roos was unavailable, thus the visit was conducted with Administrator Carlos Marcia, whom arrived at approximately 10:45 a.m.

On 09/27/2021, Administrator Carlos Marcia informed the Department of an incident pertaining to Client #1 (C1). It was communicated that on 09/26/2021, C1 unknowingly left the facility. Staff last saw C1 on 9/26/2021 between the approximate time of 6:30 p.m. and 6:45 p.m., when C1 stated they were going to lay down in their room. While passing medications that evening at approximately 7:10 p.m., staff noted that C1 had eloped from the facility. Staff went into C1’s room and discovered that C1 had stuffed pillows under the bedding to look like they were there sleeping. Staff began looking for C1 throughout the community. Between the approximate time of 9:00 p.m. and 9:30 p.m., Staff #1 (S1) located C1 in the community and prompted C1 to return home. Staff #2 (S2) attempted to assist S1 with asking C1 to return home, yet it was noted that C1 was becoming increasingly agitated. The Simi Valley Police were called and arrived at the scene and during that time, staff continued to employ de-escalation techniques to encourage C1 to return home. During that time, S1 was attacked by C1 with what looked to be a knife, and was struck several times in the head, causing injury. S1 was transported to the emergency room and C1 was arrested. C1 is not in the facility at this time.

During today’s visit, a physical plant tour was conducted at 10:16 a.m., the Administrator was interviewed at 10:52 a.m., and reviewed records at 11:30 a.m. Further investigation is required.

No deficiencies cited. Exit interview conducted. A copy of the report was issued.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021

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

LIC809 (FAS) - (06/04)

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