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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850033
Report Date: 01/27/2022
Date Signed: 01/27/2022 07:58:33 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:AAA KINDNESS CARE IIFACILITY NUMBER:
425850033
ADMINISTRATOR:PETTIFORD, SHAYNAFACILITY TYPE:
740
ADDRESS:3811 DOMINION RDTELEPHONE:
(805) 937-6444
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY:32CENSUS: 21DATE:
01/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:SHAYNA PETTIFORDTIME COMPLETED:
01:29 PM
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At 11:52am, on 1/27/2022, Licensing Program Analysts (LPA) Diaz conducted an unannounced annual inspection of the facility above.

LPA informed Administrator, Shayna Pettiford the reason for the visit. The LPA and Administrator toured the facility. At 12:11pm LPA observed all hard-wired smoke alarms and carbon monoxide detectors to be functioning properly. LPA observed all fire extinguishers to be fully charged. Paint, windows, blinds, and floors are in good repair. The common living and dining areas are clean and properly furnished. A working telephone is present. The facility is set at a comfortable temperature. The kitchen contained a sufficient supply of dishes, glasses and utensils. A seven-day supply of non-perishable food and water is present. A locked medication cabinet and First Aid Kit was observed to be complete. There is space to lock chemicals in the staff laundry room and under the kitchen sink. Sharp items are stored in a locked drawer. LPA also observed adequate supply of PPE, and toilet paper soap and paper towels.

LPA Diaz conducted Infection Control mitigation module with Administrator. No other corrections found in the mitigation module.

Exit interview conducted and report emailed

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Arien DiazTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022
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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