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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800884
Report Date: 08/28/2024
Date Signed: 08/29/2024 04:46:54 PM

Document Has Been Signed on 08/29/2024 04:46 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:SIMI OAKS COUNSELING GROUPFACILITY NUMBER:
565800884
ADMINISTRATOR/
DIRECTOR:		ERNEST W. FEDERER, PHDFACILITY TYPE:
775
ADDRESS:2345 ERRINGER ST., STE 106TELEPHONE:
(805) 581-4357
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY: 50CENSUS: 22DATE:
08/28/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:28 PM
MET WITH:Ernest FeererTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Zabel Chochian conducted an unannounced Case Management
Deficiency visit in conjunction to complaint visit (CC#29-AS-20231013151652).

LPA met with Ernest Federer, Administrator. The purpose of this visit is to issue citations for deficiencies observed during the course of the complaint investigation which was not related to the complaint (#29-AS-20231013151652).

On 10/19/2023, at approximately 10:45am five clients’ medication records and medications were reviewed with the medtech staff. Following discrepancies were observed: Client #2’s medication record indicated that there were 9 (pregabalin) pills; actual count of pills remaining in the bottle was 17; another medication (risperidone) was recorded as 18 pills remaining in the bottle, however the was 9 pills left in the bottle.

On 12/19/2023, a subsequent complaint visit was conducted and during the course of investigation it was revealed that Simi Oaks Day Program staff and ED admit to giving Client #1 (C1) tic-tacs in lieu of medication as a strategy to mitigate C1’s behaviors.


Citation issued, exit interview held, appeal rights given.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2024
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 08/29/2024 04:46 PM - It Cannot Be Edited


Created By: Zabel Chochian On 08/28/2024 at 12:30 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SIMI OAKS COUNSELING GROUP
FACILITY NUMBER: 565800884

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/28/2024
Section Cited
CCR
82702(a)(1)

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Personal Rights: (a) Each client shall have personal rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons.
This requirements not met as evidence by:
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Licensee agreed to effective immediately, discontinue the practice of using tic-tacs in lieu of medication to mitigate behaviors.
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Based on interviews licensee did not comply with the above. Executive Director and staff admit to giving Client #1 (C1) tic-tacs in lieu of medication as a strategy to mitigate C1’s behaviors.
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Type B
08/28/2024
Section Cited
CCR82705(I)

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Health-Related Services - (l)The following requirements shall apply to medications which are centrally stored:

This requirements not met as evidence by:
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Licensee removed medtech staff from medication duty. Licensee reviewed medication policy and procedures with staff. Licensee reported that he or another staff will handle the medications moving forward.
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Based on records review licensee did not comply with the above. C2’s medication record and actual pill count did not match. 9 (pregabalin) pills recorded; count of pills remaining was 17; medication (risperidone) was recorded as 18 pills; however there were 9 pills left in the bottle.
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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:Desaree Perera
LICENSING EVALUATOR NAME:Zabel Chochian
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024


LIC809 (FAS) - (06/04)
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