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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802405
Report Date: 08/23/2023
Date Signed: 08/23/2023 05:26:05 PM

Document Has Been Signed on 08/23/2023 05:26 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 50/50FACILITY NUMBER:
565802405
ADMINISTRATOR:ROOS, MARCHELINOFACILITY TYPE:
735
ADDRESS:1071 BALSAMO AVETELEPHONE:
(760) 631-7550
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY: 4CENSUS: 2DATE:
08/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Marchelino RoosTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Zabel Chcohian arrived at the facility unannounced to conduct a required annual visit. This is a level 4 home vendored by Tri-Counties Regional Center as a specialized facility CPP/Crisis.

The LPA met with Administrator Marchelino Roos and explained the reason for the visit. Upon arrival, the LPA and Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The carbon monoxide and smoke alarms were tested and all functioned properly. The fire extinguisher appeared fully charged and was last inspected on 01/24/2023. KITCHEN: Knives and cleaning supplies are stored in a locked cabinet near the kitchen. Kitchen appliances appeared to be in operable condition. Perishable and non-perishable food appeared sufficient. BEDROOMS: The LPA observed four single-occupancy client bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. RESTROOMS: Restrooms are clean and sanitary and in operating condition. COMMON SPACES: At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed the required postings throughout the facility. The backyard patio is equipped with furniture for clients' use.
CLIENT and STAFF FILES (12:45pm): Client records included but limited to, signed admission agreements, current medical assessments with TB results, current needs and services plan. Two (2) staff records reviewed, included but not limited to, the following: personnel records, health screening, criminal record statements, and current first aid certification. Staff required training on file.All files observed complete. MEDICATIONS (1:30pm): Medications are stored in a locked closet in the hallway. Medications are labeled and checked for expiration dates. No errors observed during the medication review.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2023
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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