425850033-12-28-2023-29-AS-JOLN-CYY3H6-20231228171526

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425850033
Report Date: 12/28/2023
Date Signed: 12/28/2023 05:17:24 PM

Document Has Been Signed on 12/28/2023 05:17 PM - It Cannot Be Edited

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 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:	12/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:11 AM
MET WITH:	Shayna Pettiford, Administrator		TIME COMPLETED:	05:30 PM

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Licensing Program Analyst (LPA) Jenny Olson arrived at the facility unannounced to conduct a required annual visit at 11:11 a.m. When LPA arrived, there were seven staff plus Administrator and 22 residents present. LPA was greeted by staff and Administrator shortly after and LPA informed them of the reason for the visit.

LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The facility has one large assisted living building with 3 wings and 24 rooms. LPA toured the dining room, kitchen, sunshine room, sun room, and 10 resident rooms.

Common areas: All furniture was observed to be in good condition. Carbon monoxide detectors were tested and operational at the time of the visit. There is a fireplace in the living room, which is screened and inaccessible. LPA observed required postings throughout the common spaces. The fire extinguishers were charged and serviced on 9/12/2023.
Outdoor area had a gazebo which is equipped with furniture for resident use. No bodies of water noted. Washer and dryers were functioning and in operable condition.

Restrooms: 23 restrooms were clean and sanitary and in operating condition with non-skid mats. Most rooms have their own private restroom and 4 rooms share a restroom. All resident and public bathrooms were sufficiently stocked with soap and paper towels.

KITCHEN: Knives are stored in a locked drawer in the kitchen. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food.

Continued on 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023

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: AAA KINDNESS CARE II	FACILITY NUMBER: 425850033
	VISIT DATE: 12/28/2023

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Records: LPA reviewed resident and staff records around 3:00 p.m. LPA reviewed five (5) resident files for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, and current needs and services plan. All files were complete.

LPA reviewed five (5) staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, and current first aid certification. All files were complete.

MEDICATIONS: Medications review began at 2:00 p.m. The medications are centrally stored and locked in a med cart in the foyer. Medications are labeled and checked for expiration dates. All the necessary information is properly documented on the CSMDR!

INFECTION CONTROL: The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. The facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate.

LPA interviewed three (3) staff members and three (3) residents.

During today’s visit, the LPA obtained copies of the following: staff roster and current liability insurance.

Exit interview conducted a copy of this report was issued.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023

LIC809 (FAS) - (06/04)

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