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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801923
Report Date: 06/17/2022
Date Signed: 06/17/2022 04:27:04 PM

Document Has Been Signed on 06/17/2022 04:27 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:ABUTIN CARE HOME IFACILITY NUMBER:
565801923
ADMINISTRATOR:JOYCE ABUTINFACILITY TYPE:
735
ADDRESS:603 E. IRIS STREETTELEPHONE:
(805) 240-0095
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY: 6CENSUS: 5DATE:
06/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:11 AM
MET WITH:Ben and Joyce AbutinTIME COMPLETED:
01:20 PM
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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Required - 1 Year inspection at the facility today. When the LPA arrived there was one staff and one client present. Administrators Ben and Joyce Abutin arrived during the inspection. This home is vendored by Tri-Counties Regional Center as a level three home.

This annual had 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 facility is in compliance with Title 22 Regulations. The following was observed:

KITCHEN: The kitchen and food storage areas were observed. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food stored in the kitchen and garage. Cleaning supplies and items that could pose a danger were secured in a locked cabinet.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and condition. All indoor and outdoor passages were free of obstruction. At the time of the visit, living room and dining room furniture was observed to be in good condition. The fire extinguisher was fully charged and last serviced on 07/29/2021. The carbon monoxide detector and smoke detectors in the home and bedrooms were tested and were operational. Medications are centrally stored and in a locked cabinet in the dinning room. Cleaning supplies were observed to be locked in the garage and inaccessible to residents in care. The backyard has covered seating for resident use.

BEDROOMS: There are three client bedrooms and one staff bedroom. The LPA observed the client bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Report continued on LIC 809-C.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2022
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: ABUTIN CARE HOME I
FACILITY NUMBER: 565801923
VISIT DATE: 06/17/2022
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RESTROOMS: The facility has two common restrooms for client use. Restrooms were observed to be clean and sanitary with hand soap, toilet paper and paper towels. At 11:21 the hot water temperature tested at 111.2 degrees F.

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. LPA observed all staff to be wearing masks. The LPA observed an adequate supply of Personal Protective Equipment (PPE). The facility’s cleaning protocol is sufficient. Infection control signs were posted at the entry, throughout the facility, and in the restrooms. If needed, 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.

The LPA also discussed recent incident reports pertaining Client #1 (C1) and Client #2 (C2). The licensee self-reported on 06/15/2022, that on 06/14/2022 C1 suddenly ran towards C2 and grabbed C2 resulting in an altercation between C1 and C2. Record review revealed C1 has a history of attacking their peers in the home. The Administrator stated C1 was picked up by a family member on 06/15/2022 whom decided to care for C1 at their private residence permanently.

No deficiencies cited. Exit interview and reported reviewed with the Administrator. A copy of the report was emailed. Note, due to a computer error, the Administrator's signature is not on the report. The Administrator's signature will be on the hard copy in the file.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2022
LIC809 (FAS) - (06/04)
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