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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850036
Report Date: 07/25/2023
Date Signed: 07/25/2023 05:09:51 PM

Document Has Been Signed on 07/25/2023 05:09 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:SHANNON MACKENZIEFACILITY TYPE:
735
ADDRESS:340 PABLO LNTELEPHONE:
(805) 723-5126
CITY:NIPOMOSTATE: CAZIP CODE:
93444
CAPACITY: 4CENSUS: 4DATE:
07/25/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:37 PM
MET WITH:Shannon Mackenzie, AdministratorTIME COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) De Leon conducted a case management deficiencies visit to the facility above. LPA met with Administrator Shannon Mackenzie and explained the purpose of the visit.

LPA printed a Personnel Roster for the facility prior to coming on the complaint visit on 07/25/2023 at 1:15 PM. LPA requested an up to date staff roster with telephone numbers at the facility. Administrator provided an up to date Guardian roster for the facility. Staff 1 (S1) did not appear on either roster and was not associated to work at the facility. LPA requested LPA Olson from the Goleta office to run a current Guardian roster and run a report for S1's Background Clearance. S1 did not have a clearance in the Guardian system for working in Community Care Licensing (CCL) facilities.

S1 has been the Program Director at this facility since March 2021.

Exit interview conducted, deficiency cited, civil penalty assessed, copy of report and appeal rights printed for Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE: DATE: 07/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2023
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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Document Has Been Signed on 07/25/2023 05:09 PM - It Cannot Be Edited


Created By: Rachael De Leon On 07/25/2023 at 04:48 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: PABLO LANE HOME
FACILITY NUMBER: 405850036

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/26/2023
Section Cited
CCR
80019(e)(1)

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(e) All individuals subject to a criminal record review pursuant to...shall prior to working, residing or volunteering in a licensed facility:(1)Obtain a California clearance or a criminal record exemption as required by the Department or This requirement was not met as evidenced by:
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Administrartor agreed to have staff 1 (S1) background fingerprint cleared and associated to work at the facility before working in the facility.
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Based on record review theLicensee did not comply with the regulation above the facility did not have S1 Background fingerprint cleared to work in the facility which poses an immediate health and safety risk to residents in care.
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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.
SUPERVISOR'S NAME:Kelly Burley
LICENSING EVALUATOR NAME:Rachael De Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2023


LIC809 (FAS) - (06/04)
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