<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801201
Report Date: 08/19/2022
Date Signed: 08/22/2022 04:50:17 PM


Document Has Been Signed on 08/22/2022 04:50 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: 1DATE:
08/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Lourdes RicafortTIME COMPLETED:
12:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Required 1 Year inspection at the facility today. The LPA met with Administrator Lourdes Ricafort and explained the reason for today's inspection. Today's Annual has a specific emphasis on infection control practices and procedures.

The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards
and the facility is in compliance with Title 22 Regulations. The carbon monoxide detector and smoke alarms
were tested and all functioned properly. The fire extinguisher was last serviced on 06/07/2022.

KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. The LPA observed the pantry and refrigerator to be cluttered and in need of cleaning. The pantry had ants and spiders and numerous items with past best by dates food items including pineapple juice with a best by date of 7/15/21 and an unopened cereal box with a best by date of 11/27/21. The LPA also observed ants on the kitchen counters and general clutter on the counters. The refrigerator had numerous items and sauces in unmarked containers with no dates, lunch meat with an expiration date of 4/14/18, and mayonnaise with a best by date of 11/17/21. The Administrator stated these items belonged to her and staff and was not served to the residents.

BEDROOMS: The LPA observed four resident bedrooms and one staff bedroom. Resident bedrooms
which were furnished appropriately with clean linens and sufficient lighting. Alarms on exit doors are functioning.

RESTROOMS: There is one common hallway restroom and one on suite restroom for resident use. They were both clean and sanitary and in operating condition with hand soap, paper towels, and toilet paper. The hot water measured at 109.4 degrees F in the hallway restroom.
Report continued on LIC 809-C.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2022
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 3


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: 08/19/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
COMMON SPACES: The LPA observed the required postings upon entry and though out the facility. Living room and dining room furniture was observed to be in good condition, although the table and couches were cluttered with mail and miscellaneous items. Cleaning supplies are stored in the locked garage. Medications are centrally stored in a locked cabinet in the hallway. The backyard patio is equipped with furniture for resident use.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s
infection control practices. Upon entry, the facility has a central entry point for symptom screening and
sanitation station. All facility staff were observed wearing masks. The LPA observed an adequate supply of
Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The
facility has appropriate plans in place in the event of clients and/or staff are showing symptoms of COVID or
testing positive for COVID.

The following deficiencies were cited from the CA Code of Regulations title 22. See LIC 809-D. Exit interview and report reviewed with Administrator. A copy of the report and appeal rights were emailed.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 08/22/2022 04:50 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: 08/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/23/2022
Section Cited

1
2
3
4
5
6
7
87555(b) General Food Service Requirements( 8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidence by:
8
9
10
11
12
13
14
Based on observation, the licensee failed to comply with the section cited above as the LPA observed expired food, food past the best by date, and food in unmarked containers with no dates which poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
Type B
08/23/2022
Section Cited

1
2
3
4
5
6
7
87555 General Food Service Requirements (b)(27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

This requirement is not met as evidence by:
8
9
10
11
12
13
14
Based on observation, the LPA observed spiders and ants in the pantry and ants on the kitchen counters, and clutter on the counter's, and dining room/living room area which poses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3