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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850036
Report Date: 08/27/2024
Date Signed: 08/27/2024 12:51:51 PM

Document Has Been Signed on 08/27/2024 12:51 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:
08/27/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Justin PenrodTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Rankin arrived at 9:27 am to conduct a Case Management Annual Continuation review for the 1-year annual visit to the facility above. LPA spoke with Back-up Administrator Pamela Holcombe explained the purpose of the visit. Shortly after arrival the Administrator Justin Penrod arrived.

Personnel Records & Training The facility employes 10 staff, 1 Back-up Administrator/House Manager and 1 Administrator. Staff records are kept confidential. LPA reviewed 5 staff files for 1st AID/CPR, Fingerprint clearances, Applications, Health exam with TB results, Criminal Record statement and CPI certificates. All records with the exception of 1 TB result was in the staff records. Records are kept in a locked file in the office, a Technical Advisory noted that the Administrator and House Manager should both have keys to staff records due to Licensing unable to review records on original visit, in addition the Licensing agency needs improve upon their staff record processes due to many staff documents were missing until the main office emailed the documents over to the facility. Initial and Annual Training requirements are being met.

Clients Records & Incident Reports: The Facility does handle cash resources for all 4 residents in care. LPA audited all 4 residents funds with ledgers, and cash all balancing. The facility Surety bond is current. Facility does submit incident reports to the department when required.

Continued on 809-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
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.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 08/27/2024
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Health Related Services: Facility provides transportation to medical and dental appointments when needed. Facility provides Centrally Stored Medications to all clients in care. First Aid is provided to clients in care. Clients’ medication records were reviewed and found in compliance. The facility uses a Centrally Stored Medication record printed by the pharmacy which has an area for documenting Destruct Record. The facility documents medication management through a system called Extended Care Professional (ECP) software. The system has a Medication Administration Record (MAR) for noting records of given medications.

Emergency Intervention: All staff had valid CPI Non-Violent Crisis Intervention Training Certificates.

Exit interview conducted and copy of report printed for Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
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
LIC809 (FAS) - (06/04)
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