565801923-7-6-2023-29-AS-KLOZ-CTGUB5-20230706152546

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801923
Report Date: 07/06/2023
Date Signed: 07/06/2023 04:35:42 PM

Document Has Been Signed on 07/06/2023 04:35 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 I		FACILITY NUMBER:	565801923
ADMINISTRATOR:	JOYCE ABUTIN		FACILITY TYPE:	735
ADDRESS:	603 E. IRIS STREET		TELEPHONE:	(805) 240-0095
CITY:	OXNARD	STATE: CA	ZIP CODE:	93033
CAPACITY: 6		CENSUS: 4	DATE:	07/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:09 PM
MET WITH:	Ben Abutin		TIME COMPLETED:	03:35 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. When the LPA arrived there was only one staff present as all the clients were at their day programs. Co-Administrators Ben Abutin arrived during the inspection. This home is vendored by Tri-Counties Regional Center as a level three home.

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 locked cabinets. The facility has a supply of emergency food and water.

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 07/18/2022. The fire extinguisher is scheduled for service on 07/17/2023. 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: 07/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

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 2

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: 07/06/2023

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

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 1:20 PM the hot water temperature in the common hallway restroom measured at 105 degrees F.

MEDICATIONS: Medications are locked and centrally stored in a locked cabinet in the dining room area. At 1:31 PM medications for four clients were reviewed. All medications are labeled and maintained in compliance with label instructions, and state and federal law. All medications reviewed were recorded on the centrally stored medication and destruction record. The LPA inspected the first aid kit, which was complete.

RECORDS: At 1:31 PM, the LPA reviewed P&I money and records with the Administrator. Cash resources for all four clients were separate and intact, and not be commingled with facility funds or petty cash. The facility has a current surety bond on file. The four client files reviewed were found to be complete. Four staff files were reviewed and also found to be complete. Disaster drills are conducted monthly. The facility has a 30 day supply of personal protective equipment and an emergency disaster plan on file.

INTERVIEWS: Interviews with one staff and two clients were conducted. No issues or concerns revealed.

No deficiencies were cited during today's inspection. Exit interview and reported reviewed with the Administrator. A copy of the report was provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2