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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405850036
Report Date: 08/27/2024
Date Signed: 08/27/2024 09:53:58 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/19/2023 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20230719105754
FACILITY NAME:PABLO LANE HOMEFACILITY NUMBER:
405850036
ADMINISTRATOR:SHANNON MACKENZIEFACILITY TYPE:
735
ADDRESS:340 PABLO LNTELEPHONE:
(805) 723-5126
CITY:NIPOMOSTATE: CAZIP CODE:
93444
CAPACITY:4CENSUS: 4DATE:
08/27/2024
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Pamela Holcombe, Back up Administrator TIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Residents are not adequately supervised by staff
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above to deliver final findings of the complaint investigation. LPA met with Pamela Holcombe and explained the purpose of the visit.

LPA De Leon conducted the initial complaint visit on 07/25/2023, collected records and interviewed staff around 2:00pm, 3:29pm and 4:10pm. LPA reviewed complaint, interviews, and records on 08/26/2024.

On the allegation: Residents are not adequately supervised by staff. LPA conducted interviews with staff which revealed R1 has eloping behaviors and will walk away from the facility. Staff keep eyes on R1 when R1 goes outside to smoke or when R1 leaves the property, staff are trained to follow at a safe distance and re-direct R1 as soon as able. R1 is not able to leave the facility unassisted so staff must always have sight of R1. Continued 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 29-AS-20230719105754
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: PABLO LANE HOME
FACILITY NUMBER: 405850036
VISIT DATE: 08/27/2024
NARRATIVE
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LPA Olsen called the Sheriffs Department, and they did not have any logs for the facility address for R1. LPA De Leon subpoena records and no records were able to be provided. Administrator stated there is always a staff person at the facility, residents are never left alone, staff provide supervisor in the facility and in the community. Incident reports are done for an elopement only if the staff loses sight of the resident and on July 18th staff always had R2 insight. There is insufficient evidence to support the allegation and therefore it is deemed Unsubstantiated.

Exit interview conducted and copy of report printed for Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2