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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565801923
Report Date: 10/15/2021
Date Signed: 10/15/2021 03:58:06 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
06/25/2020 and conducted by Evaluator Kasandra Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20200625135956
FACILITY NAME:ABUTIN CARE HOME IFACILITY NUMBER:
565801923
ADMINISTRATOR:JOYCE ABUTINFACILITY TYPE:
735
ADDRESS:603 E. IRIS STREETTELEPHONE:
(805) 443-6843
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY:6CENSUS: 6DATE:
10/15/2021
UNANNOUNCEDTIME BEGAN:
10:33 AM
MET WITH:Ben AbutinTIME COMPLETED:
11:40 AM
ALLEGATION(S):
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Staff spoke inappropriately towards client while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) KaSandra Lopez conducted a subsequent complaint investigation to the above facility. The purpose of the visit is to deliver findings for the above allegation. The initial visit was conducted by LPA Lopez on 06/29/2020. During today’s visit, LPA Lopez initially met with a caregiver at 10:33 AM. Entrance interview conducted. At 10:46 AM, Administrator Ben Abutin arrived at the home and the LPA informed him of the reason for today's visit.

During the initial 10-day virtual inspection, the LPA conducted a telephonic interview with the Administrator Joyce Abutin and explained the reason for the inspection. At 1:12 PM, LPA Lopez and Tri-Counties Quality Assurance Specialist (QAS) Katy Robison conducted a Face Time interview with Client #1 (C1). The LPA also requested the administrator to fax or email pertinent documentation to the LPA. On 06/30/2020, LPA Lopez and QAS Robison conducted a subsequent Face Time interview with Client #1 (C1) at 10:10 AM and with Staff #1 (S1) beginning at 10:16 AM. During the afternoon of the same day, additional Face Time interviews were conducted with Staff #2, Staff #3, and Staff #4 beginning at 2:53 PM. Report continued on LIC 9099-C.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 29-AS-20200625135956
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: ABUTIN CARE HOME I
FACILITY NUMBER: 565801923
VISIT DATE: 10/15/2021
NARRATIVE
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During today's inspection the LPA conducted a physical plant tour of the home. The LPA was informed Staff #1 (S1) no longer works at the home due the home not sharing staff with other facilities due to COVID-19 protocols.

The allegation of 'Staff spoke inappropriately towards client while in care' alleges Staff #1 (S1) told Client #1 (C1) "let's make a deal, next time you want to eat something call your mom so she can clean up your shit.". Although during the interview with S1 they denied making this exact statement, S1 admitted to using the word "shit" when talking to C1 about eating something that may make C1 sick. Based on this information, there is sufficient evidence to support the allegation that staff spoke inappropriately towards C1 occurred. Therefore, the allegation is deemed substantiated at this time.

Exit interview and report reviewed with Ben Abutin. A copy of the report and appeal rights will be emailed.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 29-AS-20200625135956
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: ABUTIN CARE HOME I
FACILITY NUMBER: 565801923
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/15/2021
Section Cited
CCR
80072(a)(1)
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80072 Personal Rights
(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:(1) To be accorded dignity in his/her personal relationships with staff and other persons.
This requirement is not met as evidenced by:
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The administrator conducted personal rights training with all staff on 08/11/2020 pertaining to this allegation. Plan of correction is cleared.
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Based on interviews, the licensee failed to comply with the section cited above as S1 admitted to talking inappropriately with C1 which poses an immediate personal rights risk to residents/clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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
06/25/2020 and conducted by Evaluator Kasandra Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20200625135956

FACILITY NAME:ABUTIN CARE HOME IFACILITY NUMBER:
565801923
ADMINISTRATOR:JOYCE ABUTINFACILITY TYPE:
735
ADDRESS:603 E. IRIS STREETTELEPHONE:
(805) 443-6843
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY:6CENSUS: 6DATE:
10/15/2021
UNANNOUNCEDTIME BEGAN:
10:33 AM
MET WITH:Ben AbutinTIME COMPLETED:
11:40 AM
ALLEGATION(S):
1
2
3
4
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9
Staff denied client access to food while in care
INVESTIGATION FINDINGS:
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3
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5
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7
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9
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12
13
Licensing Program Analyst (LPA) KaSandra Lopez conducted a subsequent complaint investigation to the above facility. The purpose of the visit is to deliver findings for the above allegation. The initial visit was conducted by LPA Lopez on 06/29/2020. During today’s visit, LPA Lopez initially met with a caregiver at 10:33 AM. Entrance interview conducted. At 10:46 AM, Administrator Ben Abutin arrived at the home and the LPA informed him of the reason for today's visit.

The allegation of 'Staff denied client access to food while in care' alleges staff did not allow Client #1 (C1) access to their dairy free frosting for a cooking class. Interviews revealed, C1 has a dairy allergy and staff were not aware that the frosting being provided to C1 was dairy free as the package was not labeled. Staff stated they did not allow C1 to use the frosting until they could get clarification on whether the item was safe for C1's use. Based on this information, the allegation is deemed unsubstantiated at this time.
Exit interview conducted and report reviewed with Ben Abutin. A copy of the report and appeal rights will be emailed.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4