<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 421703341
Report Date: 02/02/2022
Date Signed: 02/02/2022 12:10:00 PM

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:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Gregoria PitaTIME COMPLETED:
12:20 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
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. LPA 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.
At 11:15 a.m., LPA discussed items in the Infection Control Module and noted that staff have not been fit tested with N95. LPA also noted that facility does not post or have California Department of Social Services (CDSS) Provider Information Notices (PINs) posted nor available. Licensee does not receive PINs via electronic communication. The facility did not have a 30 day supply of Personal Protective Equipment (PPE). LPA counted one box of BYD N95 mask with a total count of 20 masks. The facility had 3 boxes of medium sized gloves with a total count of up to 300. Infection Control module was addressed with administrator to satisfaction.

LPA issued citation on 809D, conducted exit interview, and emailed appeal rights, report, and CDSS PINs link 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)
Page: 1 of 2