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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 421703341
Report Date: 03/22/2022
Date Signed: 03/22/2022 11:28:11 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/29/2021 and conducted by Evaluator Toan Luong
COMPLAINT CONTROL NUMBER: 29-AS-20211129114435
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: 0DATE:
03/22/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Gregoira PitaTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Facility is not meeting the needs and services of resident
INVESTIGATION FINDINGS:
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On 3/22/22 at 11:00 a.m., Licensing Program Analyst (LPA) Toan Luong conducted an unannounced complaint visit to the facility to deliver final findings of the complaint allegation. LPA met with Licensee Gregoria Pita and explained the purpose of the visit.

Allegation #1: Facility is not meeting the needs and services of resident.
LPA conducted interviews with staff and residents on 12/3/21 and 12/20/21. Interviews reveals that most of the residents can manage activities of daily living with limited assistance needed such as bathing and grooming. One resident (R1) is incontinent and would need to be changed as needed. Interview with staff and administrators reveals that 2 pads of Depend – Guards for Men – Maximum and an adult diaper Assurance Underwear for Men – Size X/XL was worn by resident during outings or bedtime. Per company item description link (https://www.depend.com/en-us/incontinence-products/men/guards-for-men?bvstate=pg:3/ct:q), pad is absorbent up to 8-10 oz. Instructions for pad is to adhere pad to underwear.
(Continued 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Toan LuongTELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 29-AS-20211129114435
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 03/22/2022
NARRATIVE
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 Per same link, company representative informed consumers that Depend has another pad designed for nighttime holding liquids up to 25-30 oz. Facility uses 2 Depend – Guards for Men – Maximum pads during an outing and nighttime for additional absorption. However, the product used by facility is not designed for nighttime and does not meet the incontinence needs of R1. LPA received subpoena medical records for R1 from Marian Regional Medical Center. Records reported that R1 was seen in the emergency room on 11/8/21 and 11/9/21 for the same symptoms. Administrators did not report R1 attending the 11/9/21 ER visit when LPA interviewed administrators on 12/20/21 and 12/3/21. LPA conducted interview with emergency room (ER) nurse on 12/21/21. Nurse reported that R1 was seen on consecutive days and reported R1 arriving at the ER with 3 soiled diapers on both days. Based on LPAs record review and interview, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 Chapter 8 Article 11. Health-Related Services and Conditions 87625 Managed Incontinence), is being cited on the attached LIC 9099D. Exit interview conducted, citation issued, and report with appeal rights emailed to administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Toan LuongTELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20211129114435
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/23/2022
Section Cited
CCR
87625(a)(1)(D)
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87625 Managed Incontinence (a) The licensee shall be permitted to accept or retain a resident who has a manageable bowel and/or bladder incontinence condition under the following circumstances: (1)The condition can be managed with any of the following:
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Facility is closing. PoC is corrected.
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(D)The use of incontinent care products. This requirement is not met as evidenced by: Based on interviews and product review, product is incorrectly used overnight exceeding the product absorption, which 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: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Toan LuongTELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3