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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610429
Report Date: 08/02/2024
Date Signed: 08/05/2024 11:22:16 AM

Document Has Been Signed on 08/05/2024 11:22 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., 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: 2DATE:
08/02/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Karine Sarkisyan, Administrator TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Angela Panushkina conducted unannounced Case Management visit to this facility in conjunction with a complaint control #31-AS-20240606085307. LPA met with the Administrator and explained the reason for the visit.

The purpose of this Case Management visit is to address the deficiencies that were observed during the initial complaint investigation conducted on 06/14/24 not related to the complaint.

During the file review and Centrally Stored Medication and Destruction Records (CSMDR), LPA observed the following:

R1 was admitted to this facility on 05/31/24 with Pro re nata (PRN) and prescribed medications (bubble pack) from the Pharmacy #1. As of 06/04/24 R1 was admitted on Hospice and a new PRN and prescribed medications (bubble pack) were delivered from Pharmacy #2. During the CSMDR record review, LPA observed all medications from Pharmacy #2 were registered/listed. However, two (2) PRN medications from Pharmacy #1 were not registered. Moreover, LPA observed the refill date for those two (2) PRN medications was on 06/05/24, but the PRN log indicated that R1 took/started the pills on 06/03/24 and 06/04/24. LPA conducted an interview with the Administrator who confirmed that R1’s previously ordered PRN medications were not registered in CSMDR, since there were less than five (5) pills left.

Deficiency issued per Title 22.

Exit interview conducted appeal rights explained and copy of this report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2024
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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Document Has Been Signed on 08/05/2024 11:22 AM - It Cannot Be Edited


Created By: Angela Panushkina On 08/01/2024 at 03:02 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: 08/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/04/2024
Section Cited
CCR
87465(h)(6)(F)

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Incidental Medical and Dental Care (h)(6) … (6) The licensee shall be responsible for assuring that a record of centrally stored prescriptions.., which includes (F) Instructions, if any, regarding control and custody of the medication.
This requirement is not met as evidenced by:
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Administrator agreed to schedule vendorized training for all staff and submit to CCL the vendor information and scheduled date of training. Training certifications to be submitted to CCL upon completion
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Based on interview and record review, the licensee did not comply with the section cited above to ensure that CSMDR were properly documented for accountability. R1’s medication was not documented properly. This poses an immediate health and safety risk to residents 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:Angela Panushkina
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2024


LIC809 (FAS) - (06/04)
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