405801971-7-1-2026-29-AS-GHTO-DVKTXY-20260701150757

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405801971
Report Date: 07/01/2026
Date Signed: 07/01/2026 03:08:28 PM

Document Has Been Signed on 07/01/2026 03:08 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:	PASO ROBLES SENIOR LIVING		FACILITY NUMBER:	405801971
ADMINISTRATOR/ DIRECTOR:	ERIC BUNTE		FACILITY TYPE:	740
ADDRESS:	380 SCOTT STREET		TELEPHONE:	(805) 227-4383
CITY:	PASO ROBLES	STATE: CA	ZIP CODE:	93446
CAPACITY: 6		CENSUS: 6	DATE:	07/01/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:50 AM
MET WITH:	Licensee/Administrator - Eric Bunte		TIME VISIT/ INSPECTION COMPLETED:	03:30 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	At 8:50am, on 7/1/2026, Licensing Program Analyst (LPA) Haner-Tomasko arrived at the facility unannounced to conduct the annual facility inspection. LPA met with Licensee/Administrator Eric Bunte, announced who he was and the reason for the visit. Lead Staff Marilyn Del Monte and LPA conducted a full tour of the facility. This facility is a two-story residential home with four resident bedrooms located on the first floor (two are dual occupancy) and one and a half bathrooms for public use. The first floor also has a living room with dining space, a kitchen and office area. Laundry machines are located in the hallway and laundry chemicals are kept in the garage. Access to the garage is through a locked door for resident safety. The second floor is for staff use only and contains a staff bedroom with en-suite full bathroom. LPA noted that the backyard has seating and shade for residents and visitors. LPA noted fresh fruit and snacks in the kitchen for residents to enjoy freely. The facility has battery operated smoke detectors in each resident bedroom and hallway leading to bedrooms that are all working, the carbon monoxide detector is in the hallway and functioning normally. LPA observed a fire extinguisher near the office area that was tagged current and in the green compression range, purchased on 4/8/2026. LPA tested facility hot water at 111.9°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 has no obstructions in hallways, doorways or exits. Medications, resident and staff records are locked in a cabinet in the office area. LPA conducted a sample medication audit and reviewed the facilities Centrally Stored Medication Records. LPA conducted a staff and resident file review. (Continued on LIC809-C)

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Garrett Haner-Tomasko
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/01/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2026

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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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: PASO ROBLES SENIOR LIVING	FACILITY NUMBER: 405801971
	VISIT DATE: 07/01/2026

NARRATIVE

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While reviewing centrally stored medication, at 10:13am, LPA noted two open insulin pens belonging to Resident #1 (R1). Staff removed the cap of the insulin pens revealing both having attached needles. LPA asked staff how many times each needle is used and staff stated they are used multiple times for R1. LPA instructed staff that per regulation needles may only be used once and the used needles need to be discarded. Staff had to ensure R1 had enough supply; LPA observed that the facility did have a box of replacement needles for R1 that had not been used. LPA noted one other resident requires insulin, LPA observed this second residents insulin pen did not have a used needle attached and staff state they do not reuse this residents needles because they have a large supply of replacement needles; LPA observed a supply of unused needles for this resident.

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

Exit interview conducted, deficiency cited on LIC809-D page, report signed, report and appeal rights provided to the Licensee.

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Garrett Haner-Tomasko
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/01/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/01/2026 03:08 PM - It Cannot Be Edited

Created By: Garrett Haner-Tomasko On 07/01/2026 at 01:39 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PASO ROBLES SENIOR LIVING	FACILITY NUMBER: 405801971
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/01/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87470(a)(3)(B)

Infection Control Requirements

(3) In addition to Section 87629, Injections, all staff who are assigned to assist residents with the self-administration of injectable medication shall observe the following procedures: (B) A syringe and needle shall only be used once per injection on one resident and then properly disposed of in accordance with the California Code of Regulations, Title 8, Section 5193. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above when staff allowed R1 to reuse needles for their insulin pens, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/02/2026
	Plan of Correction
1 2 3 4	Staff discarded all used needles during visit. Licensee stated they will locate a vendored course related to diabetes medication management for facility staff and symptoms related to diabetes that require intervention. All staff will take the course and the Licensee will submit certificates of completion to LPA on or before 7/15/2026.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Burley
NAME OF LICENSING PROGRAM MANAGER:

	Garrett Haner-Tomasko
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/01/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2026

LIC809 (FAS) - (06/04)

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