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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801926
Report Date: 07/28/2022
Date Signed: 07/28/2022 12:55:23 PM

Document Has Been Signed on 07/28/2022 12:55 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 IVFACILITY NUMBER:
565801926
ADMINISTRATOR:JOYCE ABUTINFACILITY TYPE:
735
ADDRESS:1992 NARANJA LANETELEPHONE:
(805) 988-6195
CITY:OXNARDSTATE: CAZIP CODE:
93036
CAPACITY: 6CENSUS: 6DATE:
07/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Benjamin G. Abutin Jr, AdministratorTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced required annual visit. At 12:00 p.m., the LPA was greeted and screened by the Administrator, Benjamin G. Abutin Jr. This annual had a specific emphasis on infection control practices and procedures. When the LPA arrived there was one staff and one client present. This home is vendored by Tri-Counties Regional Center as a level four I.

At 12:02 p.m., the LPA, along with Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations.

BEDROOMS: There are four client bedrooms. The LPA observed the client bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

RESTROOMS: Restrooms were observed to be clean and sanitary with hand soap, toilet paper and paper towels. At 12:03 p.m., the hot water temperature tested at 109.4-degree Fahrenheit.

KITCHEN: The LPA observed the kitchen/dining area. Knives are stored in a locked kitchen drawer. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 12:10 p.m., hot water measured at 105.2-degree Fahrenheit.

COMMON SPACES: 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 LPA observed the fire extinguisher to be fully charged and last serviced on 07/18/2022. Signs are posted throughout facility to promote handwashing, and cough/sneeze etiquette. At 12:08 p.m., fire alarms and carbon monoxide detectors were tested and functioned properly. Medications are centrally stored and in a locked cabinet in the dining room.

Continued on LIC 809-C.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE: DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2022
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 IV
FACILITY NUMBER: 565801926
VISIT DATE: 07/28/2022
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OUTDOOR SPACE: At 12:11 p.m., the LPA observed the back patio which has a covered outdoor area for resident use. There is a self-latching gate designated for an emergency exit.

GARAGE: The garage is attached to the house. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away in the garage and in the laundry room.

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, temperature checks, and a sanitation station. The LPA observed a 30-day supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. 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 has not had a confirmed case of COVID-19 at this time; however, the facility’s policies and procedures as it pertains to infection control are adequate.

No deficiencies were observed at this time. Exit interview conducted with the Administrator. Report issued and a copy of the report will be provided via email.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022
LIC809 (FAS) - (06/04)
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