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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801740
Report Date: 05/08/2025
Date Signed: 05/08/2025 01:06:03 PM

Document Has Been Signed on 05/08/2025 01:06 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:BOB & CORKY'S CARE HOMEFACILITY NUMBER:
405801740
ADMINISTRATOR/
DIRECTOR:		JOEL WOBROCKFACILITY TYPE:
740
ADDRESS:2425 GERDA STREETTELEPHONE:
(805) 400-0506
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93401
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
05/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Backup Administrator - Shawna HarneyTIME VISIT/
INSPECTION COMPLETED:
01:10 PM
NARRATIVE
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 At 08:30am, on 05/08/2025, Licensing Program Analyst (LPA) Haner-Tomasko arrived at the facility unannounced to conduct the annual facility inspection. LPA met with Backup Administrator - Shawna Harney, announced who he was and the reason for the visit.

At 09:00am Backup Administrator and LPA conducted a full tour of the facility. This facility has four resident bedrooms (two are dual occupancy), three full bathrooms (one is on-suite and two are public/shared use). There is a kitchen, dining room, and living room. Access to the laundry room and garage are through a locked door for resident safety. LPA noted that the backyard has seating and shade for residents and visitors. LPA observed residents enjoying lunch outside together at a shaded table. In the backyard there is a walkway connecting to the backyard of Bob & Corky's Home Care II. LPA noted fresh fruit in the kitchen for residents to enjoy freely. The facility has battery operated smoke detectors in each room that are all working, the carbon monoxide detector is in the dining room and functioning normally. LPA observed a fire extinguisher in the kitchen that was tagged current and in the green compression range, serviced on 03/21/2025. At 09:25am in the kitchen LPA observed a steak knife in an unlocked drawer next to the refrigerator. LPA tested facility hot water at 114.1*(f), within regulation temperatures 105*-120* (f). LPA observed at least 2-days of perishable and at least 7-days of nonperishable foods. LPA noted that the facility is clean with no obstructions in hallways, doorways or exits. Medications are locked in a cabinet in the kitchen and garage. LPA conducted a sample medication audit and reviewed the facilities Centrally Stored Medication Records. LPA conducted a staff and resident file review.

LPA and backup Administrator conducted a review of the annual care tool modules.

Exit interview, report signed, deficiencies cited on LIC809-D, appeal rights, and report provided

Kelly BurleyTELEPHONE: (805) 562-0413
Garrett Haner-TomaskoTELEPHONE: (805) 450-0283
DATE: 05/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/08/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 05/08/2025 01:06 PM - It Cannot Be Edited

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: BOB & CORKY'S CARE HOME
FACILITY NUMBER: 405801740

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above when LPA observed a steak knife left in an unlocked kitchen drawer next to the refigerator which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/22/2025
Plan of Correction
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Licnesee agrees to review the cited regulation and related subsections with staff on or before 5/22/2025. Licensee will email LPA documentation of the training and a signed roster of staff who completed the training on or before 5/22/2025
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kelly BurleyTELEPHONE: (805) 562-0413
Garrett Haner-TomaskoTELEPHONE: (805) 450-0283

DATE: 05/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2025

LIC809 (FAS) - (06/04)
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