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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850036
Report Date: 09/11/2025
Date Signed: 09/11/2025 02:26:19 PM

Document Has Been Signed on 09/11/2025 02:26 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:		PAMELA HOLCOMBEFACILITY TYPE:
735
ADDRESS:340 PABLO LNTELEPHONE:
(805) 723-5126
CITY:NIPOMOSTATE: CAZIP CODE:
93444
CAPACITY: 4CENSUS: 4DATE:
09/11/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:49 AM
MET WITH:Pamela HolcombeTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Rankin arrived unannounced to conduct a one year required annual. LPA spoke with Administrator Pamela Holcombe explained the purpose of the visit.

LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and to ensure the facility is in compliance with Title 22 Regulations. The facility is vendored by Tri-Counties Regional Center (TCRC).

Physical Plant & Environmental Safety: The facility is a 4 bedroom and 3-bathroom home currently occupying 4 residents, 1 resident is moving out today. The facility has dual smoke and carbon monoxide detectors which were working at time of visit. The pathways are clear of any obstructions. The facility has sufficient space inside and outside for activities and visiting. The facility has a backyard for client use with plenty of shade. Living and dining room furniture were observed to be in good condition. LPA observed required postings throughout the common space. No bodies of water noted. The washer and dryer are in a room near the kitchen. The door to the laundry room was locked. The separate storage unit in the back yard was locked. Disinfectants, cleaning solutions and poisons are locked in laundry room cupboards. Water temperatures were within regulation requirements. The facility has an open floor plan for easy movement for residents. LPA requested a routine schedule of cleaning be created and implemented to ensure common areas, windows, doors, walls, and floors remain disinfected for the health and comfort of clients, staff, and visitors.

Kitchen: The kitchen area was observed. Food is stored appropriately, items needing to be discarded were removed. The facility has a sufficient supply of non-perishable and perishable food items. Knives are stored in a locked cabinet in the staff area. An emergency supply of food and water was observed in closet area in the front room.


Restrooms: The two client restrooms were clean and sanitary and in operating condition with non-skid surfaces/mats. The bathrooms were sufficiently stocked with soap and paper towels.

Bedrooms: There are four (4) client rooms, which were furnished with appropriate linens and required furniture. A linen closet was located outside of the rooms and in the entry closet which stocked extra linens and towels. Continued on 809-C
NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Melisa Rankin
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 09/11/2025
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Clients Records & Incident Reports: LPA reviewed 4 client and 5 staff records. LPA reviewed client files for, but not limited to, the following: signed admission agreements, annual needs and services reviews, current medical assessments with TB results, TB results are on previous medical assessments which were achieved when files were purged, LPA requested those original TB results be pulled from archive and returned to the current file. Due to prior year reviews, LPA knows that TB results are on file due to prior visit documentation and residents are the same.

The Facility does handle cash resources for all 4 residents in care. LPA audited all 4 residents’ funds with ledgers, cash, and receipts all balancing. The facility Surety bond is current.

Personnel Records & Training: The facility employes 8 staff and 1 Administrator. LPA reviewed staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, current first aid certification. Administrator certificate expires 12/02/25. All records were complete. Records are kept locked and confidential. Initial and Annual Training requirements are being met through required training and monthly staff in-service training.

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

Disaster Preparedness: The current emergency disaster forms were available. The facility conducts monthly disaster drills. The fire extinguishers were charged and last inspected 02/25/2025. 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. The last disaster drill was conducted in 5/27/25.

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. The facility documents medication management through a system called Extended Care Professional (ECP). The system has a Medication Administration Record (MAR) for noting records of given medications.

Exit interview conducted and copy of report printed for Administrator.
NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Melisa Rankin
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2025
LIC809 (FAS) - (06/04)
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