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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801201
Report Date: 09/17/2024
Date Signed: 09/17/2024 03:52:31 PM


Document Has Been Signed on 09/17/2024 03:52 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:ABSOLUTE CARE HOMEFACILITY NUMBER:
565801201
ADMINISTRATOR:MARIA LOURDES RICAFORTFACILITY TYPE:
740
ADDRESS:1601 KIPLING COURTTELEPHONE:
(805) 986-8118
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY:6CENSUS: 2DATE:
09/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:John Davis, Interim AdministratorTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Kristin Kontilis arrived at the facility unannounced to conduct a required annual visit at approximately 11:10 am. LPA met with Staff 1 (S1) and explained the purpose of the visit. Interim Administrator John Davis arrived at approximately 12:20 pm. Interim Administrator stated Administrator Lourdes Rickport has been out of the country since on or about September 8, 2024. LPA spoke with Administrator Rickport who stated she is due to return on or about October 1, 2024.

Entrance interview conducted.
At the time of arrival, there were two residents in care and two staff on duty. The facility is a Residential Care Facility for the Elderly (RCFE) licensed for a capacity of six (6) non-ambulatory residents, one (1) of which can be bedridden. The facility has a hospice waiver for one (1) resident. Currently there are no residents on hospice, no bedridden residents, and no residents on oxygen.
LPA Kontilis toured the facility inside and outside with Interim Administrator, John Davis. LPA noted the fire extinguisher was last serviced on 6/17/2024. The carbon monoxide detector and smoke alarms are properly working. The common areas, kitchen, and bedrooms are clean and in good condition. Bedrooms are properly furnished with nightstands, lamps, bed, and dressers.
There are a total of five (5) bedrooms. Four (4) bedrooms are for resident use and one (1) bedroom is designated as a staff room. Bedroom 1 is a staff room. Bedrooms 2 and 4 are currently unoccupied. Resident 1 (R1) currently resides in Bedroom 3. Resident 2 (R2) currently resides in Bedroom 5. Bedroom 5 has a private bathroom.
There are two bathrooms in the facility. Bathroom 1 is located off the hallway. Per Staff 1 (S1) and Staff 2 (S2), Bathroom 1 is primarily the staff bathroom and the private bathroom in Bedroom 5 is utilized to shower R1 and R2 at least once a week. Interim Administrator was unsure as to why the hallway bathroom is not used for residents in care.

Please continue to 809-C, Pg 2.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024
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 5


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: ABSOLUTE CARE HOME
FACILITY NUMBER: 565801201
VISIT DATE: 09/17/2024
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The backyard has an outdoor area with paved walkways, potted plants, trees and shrubs. LPA observed an excessive amount of debris and miscellaneous items such as but not limited to, equipment, metal bedframes, mattress, wheelchairs, commodes, hanger, and chairs. There were no bodies of water noted. An outdoor shed was observed to be locked and inaccessible to residents in care.
LPA reviewed resident’s records for R1 and R2 including resident physician’s report and needs and service appraisals. LPA noted R2’s Physician’s Report is dated 4/21/2021. R2 was admitted into the facility on 7/4/2020.
Staff records were reviewed for background clearance and to ensure all staff are properly associated to the facility. Record review revealed Interim Administrator has received a background clearance but has not been properly associated to the facility.

The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in additional civil penalties.



Exit interview conducted. A copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 09/17/2024 03:52 PM - It Cannot Be Edited

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: ABSOLUTE CARE HOME
FACILITY NUMBER: 565801201

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(2)
87355(e)(2) Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)…
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above as Interim Administrator is not associated to the facility which poses an immediate health and safety risk to residents in care.
Civil Penalty Assessed.
POC Due Date: 09/18/2024
Plan of Correction
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2
3
4
Interim Administrator agrees to reach out to Administrator to get properly associated to the facility.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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2
3
4
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: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 09/17/2024 03:52 PM - It Cannot Be Edited

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: ABSOLUTE CARE HOME
FACILITY NUMBER: 565801201

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
87705(c)(5) Care of Persons with Dementia: Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above as R2’s Physician’s Report (LIC602) is dated 4/21/2021 which poses a potential health and safety risk to residents in care.
POC Due Date: 09/25/2024
Plan of Correction
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2
3
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Interim Administrator agrees to schedule an appointment to update R2's Physician's Report.
Type B
Section Cited
CCR
87307(a)(2)(C)
87307(a)(2)(C): Personal Accommodations and Services. No bedroom of a resident shall be used as a passageway to another room, bath, or toilet.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on record review and interviews conducted, the licensee did not comply with the section cited above as R1 who resides in Bedroom 3 is being showered once a week in the private bathroom of Bedroom 5 where R2 currently resides which poses a potential health, safety, and resident’s rights risk to residents in care.
POC Due Date: 09/19/2024
Plan of Correction
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Interim Administrator agrees to ensure R1 is no longer showered in the private bathroom of Bedroom 5 where R2 currently resides.
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: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 09/17/2024 03:52 PM - It Cannot Be Edited

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: ABSOLUTE CARE HOME
FACILITY NUMBER: 565801201

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
87303(a) Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interviews conducted, the licensee did not comply with the section cited above as multiple items of debris and discarded items were observed outside on the northside of the facility.
POC Due Date: 10/04/2024
Plan of Correction
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Interim Administrator agrees to have debris items discarded no later than due date. Interim Administrator agrees to provide proof of clean up via photos directly to LPA via email.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5