565801926-7-14-2023-29-AS-TCAA-CTQVDD-20230714162034

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801926
Report Date: 07/14/2023
Date Signed: 07/14/2023 04:21:26 PM

Document Has Been Signed on 07/14/2023 04:21 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 IV		FACILITY NUMBER:	565801926
ADMINISTRATOR:	JOYCE ABUTIN		FACILITY TYPE:	735
ADDRESS:	1992 NARANJA LANE		TELEPHONE:	(805) 988-6195
CITY:	OXNARD	STATE: CA	ZIP CODE:	93036
CAPACITY: 6		CENSUS: 6	DATE:	07/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Joyce and Ben Abutin		TIME COMPLETED:	03:20 PM

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Licensing Program Analyst (LPA) Teresa Camara conducted an unannounced Required - 1 Year inspection at the facility today. When the LPA arrived there were two staff present, four clients present and two clients in the community. LPA met with Co-Administrators Ben and Joyce Abutin. This home is vendored by Tri-Counties Regional Center as a level 4-I 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 dining room. Cleaning supplies were observed to be locked in the laundry room and inaccessible to residents in care. The backyard has covered seating for resident use.

BEDROOMS: There are four client bedrooms. 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: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

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: 07/14/2023

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RESTROOMS: The facility has one common restroom and one bathroom in bedroom 4 for client use. Restrooms were observed to be clean and sanitary with hand soap, toilet paper and paper towels. The hot water temperature measured at 115 degrees F.

MEDICATIONS: Medications are locked and centrally stored in a locked cabinet in the dining room area. At 1:15 PM LPA reviewed medications. 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 1:03 PM the LPA reviewed P&I money and records with the Administrator. Cash resources for all 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 client files reviewed were found to be complete. Four staff files were reviewed and also found to be complete. Disaster drills are conducted every month. The facility has a 30 day supply of personal protective equipment and an emergency disaster plan on file.

INTERVIEWS: Interviews were conducted with two staff and two clients; other clients were either in the community and were not available to be interviewed. 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: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

LIC809 (FAS) - (06/04)

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