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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610429
Report Date: 06/05/2024
Date Signed: 06/05/2024 04:59:51 PM

Document Has Been Signed on 06/05/2024 04:59 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:SIMPLE TOUCH BOARD AND CARE INCFACILITY NUMBER:
197610429
ADMINISTRATOR/
DIRECTOR:		SARKISYAN, KARINEFACILITY TYPE:
740
ADDRESS:22317 MOBILE STTELEPHONE:
(747) 444-8506
CITY:CANOGA PARKSTATE: CAZIP CODE:
91303
CAPACITY: 6CENSUS: 1DATE:
06/05/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:19 AM
MET WITH:Karine Sarkisyan- AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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On 6.5.2024 Licensing Program Manager (LPM) Nichelle Gillyard and Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted an unannounced Case Management - Deficiencies visit in conjunction with complaint control # 31-AS-20240531162143. LPM and LPA met with Administrator Karine Sarkisyan and explained the purpose of the visit.

During the visit, LPM and LPA identified (2) staff that were not finger print cleared, nor was associated with the facility. Civil penalties will be assess during the visit. This is an immediate health and safety risk to residents in care.

The following items were observed during the visit:
  • Administrator disqualification to maintain records, the lack of knowledge and following the regulations of Title XXII.
  • Insufficient staffing.
  • Medication are attainable located at the kitchen cabinet.
  • Chemicals are attainable located under the kitchen sink (Raid), under the sink of bathroom #1 (bleach), and laundry cabinet located by the hallway in between the entrance and living room (detergents).
  • The kitchen is an open concept, a sofa is located in the kitchen area blocking the stove, which is a fire hazard.
  • Common towels are used in bathroom #1 beside bedroom #2, no paper towels are available.
  • Room #2 uses oxygen tank and there is no signage of 'Oxygen in used'.
  • Facility temperature is not working.
  • Room #1 and room #3 has administrator belonging in the closet and was using space for storage. (Technical advice was given to please remove personal belongings.)
Continue to LIC 809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE: DATE: 06/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: SIMPLE TOUCH BOARD AND CARE INC
FACILITY NUMBER: 197610429
VISIT DATE: 06/05/2024
NARRATIVE
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  • LPA observe two (2) urinal bottles beside a resident in room #4 that is on a side table, this is health and sanitary issue because this could have spilled on the resident.
  • LPA/ LPM observe room #1 to have a mattress that is soak/ stain in urine.
  • No staff and residents records are available for LPM/LPA to review.
  • Observation in room #3 to have screen/blinds to be off rack.
  • Incident report for R1 needs to be submitted.
  • Room #3 current resident in hospital, medication was administered by resident themselves.
  • Solid waste needs to have tight fitting covers, not just a plastic bag, this was observe in the kitchen and bedroom #4.


LPA offered the following Technical Violation (TV) was advised to the administrator regarding:
  • A new facility sketch is needed when office will be converted to a staff living quarters.
  • Two (2) day perishable food and seven (7) day non-perishable food needs to be available in the facility.

Other: Form LIC 311F as requested is given to facility administrator at SIMPLE TOUCH BOARD AND CARE INC facility #197610429.

Exit interview. Copy of this report was given to Administrator.


SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2024
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Document Has Been Signed on 06/05/2024 04:59 PM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 06/05/2024 at 02:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SIMPLE TOUCH BOARD AND CARE INC
FACILITY NUMBER: 197610429

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/19/2024
Section Cited
CCR
87405(d)(1)-(5)

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(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (5). If the licensee is also the administrator, all requirements for an administrator shall apply.
(1) Knowledge of the requirements for providing care and supervision...
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Administrator needs to re-train to be the administrator of the facility.
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appropriate to the residents... (2) Knowledge of and ability to conform ... (3) Ability to maintain or supervise the maintenance of financial and other records. (5) Good character and a continuing reputation of personal integrity.This requirement is not met as evidenced by LPM/ LPA which poses a potential health.
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Type A
06/19/2024
Section Cited
CCR87411(a)

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Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by LPM/ LPA observation that there was no staffing to for residents which poses a potential
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Having the right number of staff is essential in order to provide care and supervision to residents. Need to hire another staff.
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 health safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Nichelle Gillyard
LICENSING EVALUATOR NAME:Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE: 06/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2024


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Document Has Been Signed on 06/05/2024 04:59 PM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 06/05/2024 at 02:41 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SIMPLE TOUCH BOARD AND CARE INC
FACILITY NUMBER: 197610429

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/06/2024
Section Cited
CCR
87309(1)

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Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.
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Poison, cleaning solutions and disinfectant located under the kitchen, laundry room, and bathroom needs to be lock and inaccessible to residents.
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This requirement is not met as evidenced by LPM/ LPA observation that there was poison, cleaning solutions and disinfectant that are kept unlock for residents which poses a potential health safety or personal rights risk to persons in care.
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Type A
06/06/2024
Section Cited
CCR87465(h)(2)

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Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by LPM/ LPA observation
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All prescription medication needs to be stored and lock away. No medication of resident and staff should be accessible.
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that there was medication in kitchen cabinet from staff and medication was observed in room #2 that was not stored which poses a potential health safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Nichelle Gillyard
LICENSING EVALUATOR NAME:Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE: 06/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2024


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Document Has Been Signed on 06/05/2024 04:59 PM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 06/05/2024 at 02:51 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SIMPLE TOUCH BOARD AND CARE INC
FACILITY NUMBER: 197610429

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/06/2024
Section Cited
CCR
87618(b)(3)(b)

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Oxygen Administration - Gas and Liquid Ensuring that the use of oxygen equipment meets the following requirements: "No Smoking-Oxygen in Use" signs shall be posted in the facility and appropriate areas.
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Oxygen sign needs to be place in appropriate area of the facility.
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This requirement is not met as evidenced by no signage as posted in room #2, which poses a potential health safety or personal rights risk to persons in care.
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Type A
06/06/2024
Section Cited
CCR87303(a)

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Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Change battery for facility termostat to operate temperate since its summer and would be very warm for residents. Sofa needs to be remove from the kitchen, this is a fire hazard.
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This requirement is not met as evidenced by observation in the hallway that facility temperature is not working. Sofa was blocking the oven in the kitchen, which poses a potential health safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Nichelle Gillyard
LICENSING EVALUATOR NAME:Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE: 06/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2024


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Document Has Been Signed on 06/05/2024 04:59 PM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 06/05/2024 at 03:11 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SIMPLE TOUCH BOARD AND CARE INC
FACILITY NUMBER: 197610429

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/06/2024
Section Cited
CCR
87470(a)(1)(b)(4)

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Infection Control Requirements: (a) A licensee shall ensure that infection control practices are maintained as follows:
After contact with blood, body fluids or other potentially infectious material, or contaminated surfaces.
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Urine bottle needs to be discarded immediatelt and not kept beside resident in room #4. Mattress that is located in room #1 needs to be dispose.
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This requirement is not met as evidenced by LPA/LPM observation there are 2 urine bottles beside a resident in roo #4. Stained mattress in room #1 needs to be dispose, these poses a potential health safety or personal rights risk to persons in care.
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Type B
06/19/2024
Section Cited
CCR87303(c)

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Maintenance and Operation: All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by observation of room#3 screen is off rack and bent, these poses a potential health safety or personal rights risk to persons in care.
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Screen window in room #3 needs to be reapired.
Type B
06/12/2024
Section Cited
CCR
87211(a)(3)

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Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.
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Incident report needs to be submitted for resident fall to Regional Office (RO).
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Nichelle Gillyard
LICENSING EVALUATOR NAME:Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE: 06/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2024


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Document Has Been Signed on 06/05/2024 04:59 PM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 06/05/2024 at 03:22 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SIMPLE TOUCH BOARD AND CARE INC
FACILITY NUMBER: 197610429

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/19/2024
Section Cited
CCR
87303

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Maintenance and Operation: Solid waste shall be stored and disposed of as follows: All containers, except movable bins, used for storage of solid wastes shall have tight-fitting covers on the containers; shall be in good repair; shall have external handles; and shall be leakproof and rodent-proof.
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Proper disposable trash bin that has a tight fitting cover is needed within the facility.
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This requirement is not met as evidenced by kitchen and bathroom #2 in bedrioom #4 has only trash bags hanging on a drawer handle for trash, these poses a potential health safety or personal rights risk to persons in care.
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Type B
06/19/2024
Section Cited
CCR87307

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Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths...The use of common wash cloths and towels shall be prohibited
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Have paper towel to wipe residents hands ready in all of the bathrooms.
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This requirement is not met as evidenced by and bathroom #1 has no paper towel, these poses a potential health safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Nichelle Gillyard
LICENSING EVALUATOR NAME:Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE: 06/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/05/2024 04:59 PM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 06/05/2024 at 03:34 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SIMPLE TOUCH BOARD AND CARE INC
FACILITY NUMBER: 197610429

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/19/2024
Section Cited
CCR
87506(a)

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Resident Records: (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
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No records are available for LPA to review.
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This requirement is not met as evidenced by residents has no records which poses a potential health safety or personal rights risk to persons in care.
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Type B
06/19/2024
Section Cited
CCR87412

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Personel records: The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee.
This requirement is not met as evidenced by and staff has no records these poses a potential health safety or personal rights risk
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Staff records needs to be ready for LPA to review.
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to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Nichelle Gillyard
LICENSING EVALUATOR NAME:Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE: 06/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/05/2024 04:59 PM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 06/05/2024 at 03:46 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SIMPLE TOUCH BOARD AND CARE INC
FACILITY NUMBER: 197610429

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/06/2024
Section Cited
CCR
87355(b)

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Prior to the Department issuing a license, the applicant, administrator and any adults other than a client, residing in the facility shall have a criminal record clearance or exemption.
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Association of staff to the facility is a must with Guardian in order to work within the facility.
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This requirement is not met as evidenced by two (2) staff was not associated with the facility which poses a potential health safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Nichelle Gillyard
LICENSING EVALUATOR NAME:Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE: 06/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2024


LIC809 (FAS) - (06/04)
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