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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801923
Report Date: 06/30/2022
Date Signed: 06/30/2022 05:03:56 PM

Document Has Been Signed on 06/30/2022 05:03 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: 4DATE:
06/30/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Joyce AbutinTIME COMPLETED:
03:50 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 Case Management - Incident inspection at the facility today to follow up on a self reported Special Incident Report (SIR) received. Tri-Counties Regional Center Quality Assurance Specialist (QAS) Katy Robison was also present. Administrator Joyce Abutin arrived at the facility at 3:21 PM.

On 06/15/2022, the licensee submitted a SIR regarding an incident that occurred on 06/14/2022 pertaining to Client # 1 (C1) and Client #2 (C2). It was reported that C1 suddenly ran towards C2 and grabbed C2 resulting in an altercation between C1 and C2. Previous record review revealed C1 had a history of attacking their peers in the home. On 06/15/2022, C1 moved out of the facility.

During today's inspection, the LPA and QAS conducted interviews with Client #3 (C3) and Client #4 (C4) between 2:50 PM and 3:20 PM. Both C3 and C4 witnessed the 06/14/2022 altercation between C1 and C2 after it began. No immediate health or safety concerns were observed during today's visit. No deficiencies are being cited at this time.

Exit interview and report reviewed with Joyce Abutin. A copy of the report will be emailed.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 06/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/30/2022
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 1