405850036-8-21-2024-29-AS-MRAN-D8CRSC-20240821131630

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405850036
Report Date: 08/21/2024
Date Signed: 08/21/2024 01:16:45 PM

Document Has Been Signed on 08/21/2024 01:16 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 HOME		FACILITY NUMBER:	405850036
ADMINISTRATOR/ DIRECTOR:	JUSTIN PENROD		FACILITY TYPE:	735
ADDRESS:	340 PABLO LN		TELEPHONE:	(805) 723-5126
CITY:	NIPOMO	STATE: CA	ZIP CODE:	93444
CAPACITY: 4		CENSUS: 4	DATE:	08/21/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:50 AM
MET WITH:	Justin Penrod		TIME VISIT/ INSPECTION COMPLETED:	01:30 PM

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Licensing Program Analyst (LPA) Rankin arrived at 9:50 am to conduct a 1 year annual visit to the facility above. LPA spoke with Program Director (PD) Pamela Holcombe over the phone and explained the purpose of the visit, PD is currently out with covid. A staff member provided LPA with a tour until Administrator Justin Penrod arrived to assist in the annual visit.

A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit:

Physical Plant & Environmental Safety: The facility is a 4 bedroom and 2-bathroom home currently occupying 4 residents. The facility has dual smoke and carbon monoxide detectors which were working at time of visit. The lighting and lamps in resident rooms are sufficient for the use of the facility and for resident’s comfort. The facility kitchen is clean, safe, and sanitary. The showers have non-skid mats. Toilet, hand washing and bathing facilities are operational. The pathways are clear of any obstructions. Facility is well lit inside for safety, lighting for outside requires new bulbs which will be replaced by the end of the day. Disinfectant, cleaning solutions and poisons are locked in laundry room cupboards. The facility has sufficient space inside and outside for activities and visiting. The facility has a backyard for client use with plenty of shade. The facility has telephone and internet service for resident use. Water temperatures were within regulation requirements. Facility has open floor plan for ease of movement for residents. LPA requested a routine schedule of cleaning be created and implemented to ensure common areas, windows, doors, walls, and floors remain free of dirt build-up and odors.

Continued 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024

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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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: 08/21/2024

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Operational Requirements: The Facility is operating in compliance with the granted fire clearance. The facility has exiting door alarms, window and screen alarms present and working. The facility has current liability insurance and expires on 10/01/2024. The facility is approved for a capacity of 4 Ambulatory.

Clients Rights - All required postings were posted in the common area of the facility, Personal rights and Persons with disabilities as well as the CCL Complaint poster. The current license along with CCL PIN's were posted. Internet is provided to each client and each client is given confidentiality and privacy.

Clients Records & Incident Reports: The facility keeps separate files on each resident confidential. Four files were reviewed for signed Admission Agreements, Medical Assessments LIC. 602A Physicians Report, ID, and Emergency contact forms, Appraisal Needs and Services plans (ANS) are done as IPP and ISP and completed quarterly and annually, TB results, Personal Rights, and Safeguard for personal property and valuables were present in files.

Food Service: The facility handles and prepares food safely. The facility has 2-day perishables and 7-day non-perishables to meet the food service requirement. All food is covered, stored, and marked appropriately. Food, snacks, and drinks are available when the residents want them. Emergency supply of food and water is available. Cleaning solutions and equipment are stored separately than food supply. Kitchen areas are kept clean and free from litter, rodents, vermin, and insects. Kitchen staff are observed for personal hygiene and food sanitation practices.

Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts monthly disaster drills. The fire extinguishers were charged and last inspected 02/13/2024. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency.

Exit interview conducted and copy of report printed for Administrator.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024

LIC809 (FAS) - (06/04)

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