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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850036
Report Date: 09/17/2021
Date Signed: 09/17/2021 12:32:58 PM

Document Has Been Signed on 09/17/2021 12:32 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:PABLO LANE HOMEFACILITY NUMBER:
405850036
ADMINISTRATOR:MACK, JEANNETTEFACILITY TYPE:
735
ADDRESS:340 PABLO LNTELEPHONE:
(805) 723-5126
CITY:NIPOMOSTATE: CAZIP CODE:
93444
CAPACITY: 4CENSUS: 4DATE:
09/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:11 AM
MET WITH:Jeannatta Mack/AdministratorTIME COMPLETED:
12:30 PM
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 At 9:00am on 09/17/2021, Licensing Program Analyst (LPA) Jeffries conducted a screening call with Staff Emanuel Luis-Roman to get facility COVID-19 status. No residents or staff with any symptoms or positive status, additionally, the facility had conducted third round mass of testing the day prior (09/17/2021) due to current positive status.
At 9:15am, due to the facilities current COVID-19 positive status, LPA dawned full Personal Protective Equipment (PPE) and then entered the facility. LPA conducted a cursory tour of the facility with staff Emanuel Luis-Roman. The facility is a 4 bed room 2.5 bath with office laundry room, dining room and two common room living areas. LPA observed COVID-19 precautions and reporting instructions on the wall of the facility as well as all required posted information per regulations on facility wall in common area of the dining room and the staff office. LPA observed each room was properly equipped and outfitted per regulations. LPA observed all three bathrooms to be stocked and functioning per regulations. LPA observed a medication cart in the second living room that was secured by lock and key. LPA observed more than two days of perishable and 7 days of non-perishable foods. LPA observed working smoke detectors/carbon monoxide detectors in all rooms and the hallway of the facility. LPA observed all hazardous material were locked in by lock and key in the laundry cabinet and all sharps were secured in the staff office. LPA observed the facility single entry point log-in book and all staff currently at the facility had been screened for COVID-19 and logged in prior to their shift. The facility was clean and appeared to be free of any hazards on the cursory Infection Mitigation Control Inspection. At 10:21am LPA conducted the Infection Mitigation Control Module of the Inspection with Administrator Jeannett Mack . LPA reminded Administrator that all persons who enter the facility need to be screened for COVID-19 prior to entry to the facility. LPA also reminded Administrator that all staff must have a mask on at all times while in the facility. LPA and Administrator completed the Infection Mitigation Control Module of the inspection.

Exit Interview, no citations issued, report emailed
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2021
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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