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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 421703341
Report Date: 02/02/2022
Date Signed: 02/02/2022 12:31:37 PM

COMPREHENSIVE INSPECTION
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:PITA BOARD AND CAREFACILITY NUMBER:
421703341
ADMINISTRATOR:CHRISTINE PITAFACILITY TYPE:
740
ADDRESS:259 MOONCRESTTELEPHONE:
(805) 934-2649
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY:6CENSUS: 4DATE:
02/02/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Gregoria PitaTIME COMPLETED:
12:40 PM
NARRATIVE
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On 02/02/22 at 10:20 a.m., Licensing Program Analyst (LPA) Toan Luong conducted an unannounced One Year Annual visit to the facility. At 12:20 p.m, LPA continued the annual visit due to a technical error issuing a deficiency from previous annual visit report. LPA met with Administrator Gregoria Pita and explained the purpose of the visit.

At 10:29 a.m., LPA opened a utensil drawer in the kitchen and observed one pairing knife and 2 scissors in the drawer. The blades of the knife and scissors were approximately 3 inches long. LPA asked staff why items were left here, and staff replied that it was forgotten there after cutting bread in the morning. LPA asked administrator if there are any dementia residents. Administrator replied yes.

LPA issued citation on 809D, conducted exit interview, and emailed appeal rights and report to the administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Toan LuongTELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022
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: PITA BOARD AND CARE
FACILITY NUMBER: 421703341
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/03/2022
Section Cited

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87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement was not met as evidence by:
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LPA found 1 knife and 2 scissors in a unlocked utensil drawer. Based on observation and interview, the licensee did not comply with regulation above in 1 count which poses an immediate health, safety, or personal rights risks 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: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Toan LuongTELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2022
LIC809 (FAS) - (06/04)
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