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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610429
Report Date: 12/11/2024
Date Signed: 12/11/2024 06:40:11 PM

Document Has Been Signed on 12/11/2024 06:40 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., 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: 3DATE:
12/11/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Karine Sarkisyan, Administrator TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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At 9:00am, Licensing Program Analyst (LPA) Angela Panushkina and Regional Director, LTC Ombudsman Program, Ginger Perini, conducted unannounced visit to this facility in conjunction with a complaints, control #31-AS-20241205141612 and #31-AS-20241209084739. The team met with Staff #1 (S1), Chinara Atamkulova, who granted access to the facility. Administrator arrived shortly after, and the team explained the reason for the visit.

During the visit, the team was informed of the following:
  • Upon arrival the team observed the front entrance locked (padlock) to which staff had to retrieve the key to open the door. Interview with the Administrator and S1 revealed that the door is being locked with a lock from the inside to prevent R1 from leaving the facility. The team was also informed that only the staff has an access to open the lock.
  • S1 started working here as of 12/06/2024. LPA conducted review of Licensing Information System and did not observe S1's association to this facility. LPA informed the Administrator that all staff members must be fingerprint cleared and associated prior to employment.
  • Administrator informed the team that R1 moved to this facility on 11/22/24 and from 11/22/24 to present, R1 refused to take all six (6) prescribed medications.
  • The team observed R1's file missing Admission Agreement, Physician's Report and some forms missing signatures/dates and or incomplete.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are cited and noted on LIC 809D.
Exit interview conducted, appeal rights and copy of report signed and delivered.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2024
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 12/11/2024 06:40 PM - It Cannot Be Edited


Created By: Angela Panushkina On 12/11/2024 at 02:11 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: 12/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/13/2024
Section Cited
CCR
87468.2(a)(6)

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Additional Personal Rights of Residents in Privately Operated Facilities: (a) In addition to the rights... resident shall have all of the following personal rights: (6) To make choices concerning their daily lives in the facility.
This requirement is not met as evidenced by:
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Administrator shall remove the lock that require key on entrance/exit door and submit picture proo. In-service training will be conducted with all staff and copy of the training will be submitted to LPA by POC date
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Based on observation, the licensee did not comply with the section cited above by placing a lock on a main entry door to preventing R1 from leaving/wondering out. This poses an immediate health, safety or personal rights risk to persons in care.
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Type A
12/13/2024
Section Cited
CCR87355(e)(2)

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Criminal Record Clearance: (e) All individuals subject to a criminal record review... shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified...
This requirement is not met as evidenced by:
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Administrator has agreed to have S1 get fingerprinted. Administrator will provide an updated LIC500 to reflect new staff.
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Based on record review, the licensee did not comply with the section cited above. S1's first day of work was on 12/06/24 and as of 12/11/24 S1 is not associated to the facility which poses an immediate health, safety 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:Angela Panushkina
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 12/11/2024 06:40 PM - It Cannot Be Edited


Created By: Angela Panushkina On 12/11/2024 at 02:25 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: 12/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/18/2024
Section Cited
CCR
87506(b)(15)

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Resident Records: (b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal...

This requirement is not met as evidenced by:
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Licensee agreed to review and complete all facility residents' files. Licensee/administrator will submit a written statement notifying the department what steps will be taken to clear this deficiency and to ensure such deficiency will not reoccur.
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Based on LPAs inspection and observation, the licensee did not comply with the section cited above. R1 was admitted on 11/22/24 and records were incomplete and or missing documents, which poses/posed a potential health and safety 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:Angela Panushkina
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 12/11/2024 06:40 PM - It Cannot Be Edited


Created By: Angela Panushkina On 12/11/2024 at 02:38 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: 12/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/13/2024
Section Cited
CCR
87465(c)(2)

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87465 Incidental Medical and Dental Care:
c) If the resident's physician has stated in writing... 2) Once ordered by the physician the medication is given according to the physician's directions.
This requirement is not met as evidenced by:
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Administrator agreed to schedule vendorized training for all staff by 12/13/2024 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 record reviews and interviews, licensee did not comply with the section above to ensure R1 took prescribed medication from 11/22/24-12/11/24. 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: 12/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2024


LIC809 (FAS) - (06/04)
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