425850033-9-8-2022-29-AS-KBUY-CJ7TYT-20220912150916

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425850033
Report Date: 09/08/2022
Date Signed: 09/08/2022 01:30:34 PM

Substantiated

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
09/07/2022 and conducted by Evaluator Jeannette Olson

COMPLAINT CONTROL NUMBER: 29-AS-20220907122927

FACILITY NAME:	AAA KINDNESS CARE II		FACILITY NUMBER:	425850033
ADMINISTRATOR:	PETTIFORD, SHAYNA		FACILITY TYPE:	740
ADDRESS:	3811 DOMINION RD		TELEPHONE:	(805) 937-6444
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93454
CAPACITY:	32	CENSUS: 25	DATE:	09/08/2022
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Shayna Pettiford, Administrator		TIME COMPLETED:	01:40 PM

ALLEGATION(S):

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Facility not providing a comfortable temperature for residents in home.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA's) Olson and Cortez conducted an initial complaint investigation for the allegation listed above. LPA's arrived at the facility at 11:00 AM and met with Sheryll Ann, Health Services Director. Administrator arrived around 11:15 AM. LPA's toured the inside and outside of the facility with Administrator. LPA's interviewed residents between 11:10 AM and 12:0 0PM, a staff around 11:34 AM and Administrator around 12 PM. LPA's reviewed and obtained copies of pertinent documents.

During the facility tour and upon arival LPA's noticed the facility temperature was very warm. Interviews revealed only part of the facility has air conditioning. LPAs measured 12 room tempurates between 11:20 AM and 11:50 AM. The sun room was 86.2, Resident 1 room (R1) was 86.5, Resident 2- 89.2, Resident 3- 87.2, Resident 4- 86.9, Resident 5- 79, Rec room was 84.7, Resident 6- 84.9, Resident 7- 84.4, Activities Room- 79.8, Hall 78.1, and Resident 7- 79.2.

Continued on 9099--C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220907122927

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: AAA KINDNESS CARE II	FACILITY NUMBER: 425850033
	VISIT DATE: 09/08/2022

NARRATIVE

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It was alleged that residents rooms were over 93 degrees this week and was not a comfortable temperature. LPA's observed the temperature outside at 85 degrees Fahrenheit upon arrival to the facility. LPA's confirmed that has been an excessive heat warning throughout the area issued at this time. LPA's thermometer readings varied between 78.1 degrees and 89.2 degrees Fahrenheit. Based on observation, The allegation that Facility not providing a comfortable temperature for residents in home is deemed SUBSTANTIATED at this time.

Administrator Interview revealed that once they were made aware of the hot temperature in a residents room they immediately got a fan for the resident and called stores to find an AC unit. Administrator stated that an hour after they were informed a portable AC unit was delivered to the room to cool it down. Administrator also stated that the facility is doing frequent checks on residents, reminding them to stay hydrated and encouraging them to do activities and hang out in the sunshine room that has air conditioning.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Exit interview conducted, a copy of reports and appeal rights were reviewed and provided to the Administrator via email.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220907122927

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: AAA KINDNESS CARE II	FACILITY NUMBER: 425850033
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/08/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/09/2022 Section Cited CCR 87303(b)	1 2 3 4 5 6 7	87303 (b) A comfortable temperature for residents shall be maintained at all times. (2) The facility shall cool rooms to a comfortable range, between 78 degrees F (26 degrees C) and 85 degrees F (30 degrees C)... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administraor Agreed to create a plan to ensure the facility rooms are at a comforatble range bellow 85 degrees and submit the plan to CCL by 9/9/22. Administraor will send updates to LPA on facility temperature around 3 PM every day for the next 3 days.
	8 9 10 11 12 13 14	Based on observation the temperatures inside the facility measured as high as 89 degrees Fahrenheit, which poses an immediate health, safety and personal rights risk to residents in care	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022

LIC9099 (FAS) - (06/04)

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