565802405-5-2-2022-29-AS-ASMH-CE2N3W-20220502100701

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565802405
Report Date: 05/02/2022
Date Signed: 05/02/2022 10:07:37 AM

Document Has Been Signed on 05/02/2022 10:07 AM - 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: 3	DATE:	05/02/2022
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Marchelino Roos		TIME COMPLETED:	10:00 AM

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Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced Case Management - Incident visit, to conclude an investigation that began on 09/28/2021. The LPA met with Marchelino Roos and explained the reason for the visit.

On 09/27/2021, Administrator Carlos Marcia informed the Department of an incident pertaining to Client #1 (C1), in which C1 eloped from the facility. The incident ultimately led to the assault of Staff #1 (S1). During the initial visit, a physical plant tour was conducted at 10:16 a.m., the Administrator was interviewed at 10:52 a.m., and documents were requested. Interviews were conducted with staff on 11/17/2021 at 3:10 p.m., 3:53 p.m., and 4:24 p.m., and on 11/19/2021 at 3:10 p.m.

The investigation revealed that on 09/26/2021, C1 unknowingly left the facility. Staff last saw C1 on 9/26/2021 at around 6:30 p.m. While passing medications that evening at around 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. Further investigation confirmed that C1 had eloped from the facility by way of leaving through the window of the adjacent client’s room. That client’s window did not have an alarm, hence staff were not aware that C1 had used the window to leave the facility. Upon noticing that C1 was gone, the runaway safety protocol was engaged, and 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. S1 made contact with facility staff, and Staff #2 (S2) arrived to the location and attempted to assist S1 with asking C1 to return home. Interviews revealed that C1 became 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. S2’s earpiece fell out of their ear in front of C1, and as S1 went to pick it up, 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.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/02/2022

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During the course of the investigation, it was noted that C1 did not have an assigned 1:1 staff person at that time. In addition, as C1 had previously eloped from the facility, staff had placed an alarm on C1’s sliding glass door in order to alert staff. As C1 had previously eloped from their sliding glass door, staff were unable to anticipate that C1 would attempt to elope from the facility from another client’s window. Interviews reviewed that C1 displayed normal baseline behaviors prior to informing staff that they were going to their room that evening. There was approximately 15-30 minutes between the time that staff had last seen C1 to when they went to C1’s room to assist with the self-administration of medication. Based on the investigation, there is insufficient evidence to support the claim that C1 eloped from the facility due to lack of supervision.

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

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2022

LIC809 (FAS) - (06/04)

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