<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850036
Report Date: 10/22/2024
Date Signed: 10/22/2024 01:09:07 PM

Document Has Been Signed on 10/22/2024 01:09 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:PABLO LANE HOMEFACILITY NUMBER:
405850036
ADMINISTRATOR/
DIRECTOR:		JUSTIN PENRODFACILITY TYPE:
735
ADDRESS:340 PABLO LNTELEPHONE:
(805) 723-5126
CITY:NIPOMOSTATE: CAZIP CODE:
93444
CAPACITY: 4CENSUS: 4DATE:
10/22/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Pam HolcombeTIME VISIT/
INSPECTION COMPLETED:
01:15 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 9:15 am on 10/22/24, Licensing Program Analyst (LPA) Rankin and Tri Counties Regional Center (TCRC), Quality Assurance Specialist (QA) Jeff Edler arrived at the facility unannounced to conduct a Case Management (CM) visit based on a self-reported incident by the facility and a concern with facility items brought up during Annual visits. LPA and QA met with Program Director Pam Holcombe and explained the reason for the visit.

A TCRC incident report dated 10/4/24 reported that on 10/3/24 two (2) clients were taken out in a staff personal vehicle to an unknown home and left in vehicle for an unknown amount of time. During the CM visit LPA and QA discussed the event with the Program Director. Program Director stated staff took personal vehicle for an hour and a half with 2 clients. Per interview conducted with Client #1 via the Program Director, when they arrived at an unknown location the staff went in one car and the clients were left in another. The cars were next to each other, and no one went inside the house. Per Program Director the clients didn’t seem upset. Per Program Director the policy is that they must be pre-approved to use their personal vehicle for clients. An internal investigation was done by Licensee’s Quality Inspector and Staff 1 was terminated. Currently Staff 2 is employed, but Program Director is unsure of any disciplinary actions or discussions.

The LPA reviewed two (2) client files and two (2) staff files. Physician reports for client’s state one can leave the facility unassisted and the other one cannot. Program Director was advised to conduct a discussion / training where staff acknowledge the rules and policies regarding safety of clients, use of personal vehicles for clients, and policy regarding errands during work hours.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE: DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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: PABLO LANE HOME
FACILITY NUMBER: 405850036
VISIT DATE: 10/22/2024
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
26
27
28
29
30
31
32
Program Director stated going forward there will be a discussion with staff regarding the use of their vehicles and monthly review ensuring the proper insurance is current and valid. LPA and QA will be setting up a discussion with the Licensee’s Area Director and Quality Inspector to better understand the licensees’ policies, the action taken following this event, and the interviews that occurred during their investigation.

During the visit a brief tour of the facility was done to review bathrooms, and common areas, on prior visits dated 8/21/24 and 8/27/24 LPA smelled a strong urine smell in the facility. During prior visits Program Director and Area Director stated they were having a plumber come and address the concerns as well as using an enzyme chemical for smell breakdown. It was later learned this was a similar conversation that was had with TCRC’s QA Edler on 8/5/24 during their annual review. During todays visit the smell was initially not as intense, but as time went on the air freshener smell dissipated and from across the facility the smell of urine could still be detected. Due to issue persisting for over 2 months a deficiency will be given requiring the licensee to take additional action to address the smells. The air freshener is very strong, and the urine smell is strong which poses a violation to Title 22 regulations requiring home with incontinent clients remain free of odors.

Exit interview conducted, a copy of the deficiency, appeal rights and this report was given to the Program Director.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 10/22/2024 01:09 PM - It Cannot Be Edited


Created By: Melisa Rankin On 10/22/2024 at 11:44 AM
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: 10/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/22/2024
Section Cited
CCR
80077.4(a)(4)

1
2
3
4
5
6
7
80077.4 Care for Clients with Incontinence (a) A licensee of an adult CCF may...retain a client who has... bladder incontinence. (4) Ensuring that...the facility remains free of odors.
1
2
3
4
5
6
7
A professional is evaluating the bathrooms to work at locating and deep cleaning the urine issue. An invoice will be provided to licensing stating work done. If this does not control the smell the administrator
8
9
10
11
12
13
14
Based on observation and interviews, the licensee did not comply with the section cited above in that on 3 occassions the LPA has smelled an intense Urine smell throughout the facility.
8
9
10
11
12
13
14
will notify CCL and work on next steps.
Invoice and results will be emailed to CCL no later than 11/22/24.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Melisa Rankin
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3