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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801926
Report Date: 07/30/2024
Date Signed: 07/30/2024 01:39:54 PM

Document Has Been Signed on 07/30/2024 01:39 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:ABUTIN CARE HOME IVFACILITY NUMBER:
565801926
ADMINISTRATOR/
DIRECTOR:		JOYCE ABUTINFACILITY TYPE:
735
ADDRESS:1992 NARANJA LANETELEPHONE:
(805) 988-6195
CITY:OXNARDSTATE: CAZIP CODE:
93036
CAPACITY: 6CENSUS: 6DATE:
07/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:54 AM
MET WITH:Ben and Joyce AbutinTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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Licensing Program Analysts (LPA) Erica Mosley and Licensing Program Manager KaSandra Lopez arrived at the facility unannounced to conduct a required annual visit and entered the facility at 9:54 a.m. Upon arrival, there were no staff and none of the six (6) residents present. Residents were at day program. The LPAs met with administrators Benjamin and Joyce Abutin and the reason for the visit was explained and entrance interview was conducted.

The LPAs 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.

KITCHEN: The LPA inspected the kitchen/food service area at 9:56 a.m. Knives and sharps were observed in a locked cabinet. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. The kitchen faucet was measured for hot water temperature, and it measured 110 degrees Fahrenheit at 10:00 a.m.

COMMON AREAS: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. At 10:12 a.m., smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguishers were observed and fully charged on 07/16/2024. The LPAs observed required postings throughout the common space. The last emergency disaster drill took place on 07/07/2024. Activities were observed in the common areas.

Report Continued on LIC 809C...

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE: DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/30/2024
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ABUTIN CARE HOME IV
FACILITY NUMBER: 565801926
VISIT DATE: 07/30/2024
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RESTROOMS: The two (2) resident restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured; the first bathroom measured at 119 degrees Fahrenheit at 10:02 a.m.

BEDROOMS: There are 4 (four) total bedrooms in the facility; two (2) are designated as a shared room, two (2) are designated as private resident rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting.

GARAGE/BACKYARD: The garage is maintained locked at all times. There is a washer and dryer on premises. Laundry detergent was observed in a locked cabinet above the washer and dryer. LPAs observed an adequate amount of emergency food and water. Cleaning supplies are kept in the garage locked and inaccessible to residents in care. The backyard has a covered patio area with patio furniture including a table and chairs for resident use. All passageways were observed to be clear. LPAs observed one (1) self-latching gate. There were no bodies of water noted at the time of the visit.



MEDICATIONS: Medications review began at approximately 10:19 a.m. The medications are locked in a cabinet adjacent to the kitchen. Medications for four clients were reviewed. Medications reviewed were found to be self-administered as prescribed and documented on the centrally stored medication and destruction records.


RECORDS: The LPA and Administrator reviewed P&I money at 10:39 a.m. for three clients. Cash resources were found to be separate and intact and not commingled with facility funds or petty cash. Resident Records were reviewed beginning at 10:50 a.m. and personnel records at 11:18 a.m. Six (6) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan.

Report Continued on LIC 809C...

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ABUTIN CARE HOME IV
FACILITY NUMBER: 565801926
VISIT DATE: 07/30/2024
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Five (5) personnel files including the Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order.

INTERVIEWS: Two (2) staff interviews were conducted. There were no clients available for interview during the inspection.

No deficiencies were cited during today’s inspection. Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024
LIC809 (FAS) - (06/04)
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