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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405850036
Report Date: 12/19/2025
Date Signed: 12/19/2025 03:27:04 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/18/2025 and conducted by Evaluator Melisa Rankin
COMPLAINT CONTROL NUMBER: 29-AS-20251218100949
FACILITY NAME:PABLO LANE HOMEFACILITY NUMBER:
405850036
ADMINISTRATOR:PAMELA HOLCOMBEFACILITY TYPE:
735
ADDRESS:340 PABLO LNTELEPHONE:
(805) 723-5126
CITY:NIPOMOSTATE: CAZIP CODE:
93444
CAPACITY:4CENSUS: 4DATE:
12/19/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Pamela HolcombeTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not provide proper care and supervision
Facility did not follow reporting requirements
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Rankin along with Tri-Counties Regional Center (TCRC) Quality Assurance Specialist (QAS) Miquel Magana conducted an initial 10-day complaint visit to the facility above. LPA met with Pamela Holcombe and explained the purpose of the visit.

During the investigation, LPA Rankin conducted interviews, reviewed and collected relevant documents, and toured the facility. Throughout the investigation LPA interviewed 2 witnesses, one of which was a responding sheriff, 4 staff, including the administrator, and observed a brief interview with Client 1 (C1).
Page 1 (Continued on 9099-C)

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 29-AS-20251218100949
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/19/2025
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
On the allegation: Staff did not provide proper care and supervision

It was alleged that C1 left the facility property on at least two occasions, once on 12/17/25 and another on a date unknown. On both occasions, C1 reportedly approached the neighboring property and allegedly banged on the door and windows.

On 12/17/25 witnesses stated that C1 jumped over the fence onto the neighboring property, banged on the door, was told to leave, at which point C1 jumped back over the fence. Witnesses stated that an attempt to call into the open front door for staff to assist was made, following this attempt with no results C1 followed the individual and again left the facility property and entered the neighbor’s property and into their garage. Responding officers arrived shortly after.

For the incident on 12/17/25, an image was provided showing C1 inside the neighboring yard while law enforcement was outside the fence appearing to be speaking to C1. In this image, C1 was wearing a light grey sweatshirt, black shorts, black socks and slip on shoes as well as a blue pointy costume hat. Second image shown showed C1 wearing same hat with same clothing walking down the driveway, towards the street past the white van in the driveway. In both images, no staff member is visible. LPA interviewed a responding Sheriff at 9:18 a.m. on 12/19/25 who confirmed that when officers arrived client was inside the neighbor’s fence and there were no staff present. Officer stated they went up to the facility front door and asked staff to come out and assist with C1. Officer stated they observed 2 staff.

Incident report provided by administrator claims that the “client ran out the front door, jumped over the neighbor’s fence and started pounding on their door, it further claims that “staff caught up with [C1] and redirected [C1] back to the Pablo home, but the police had already been called.” Report also states that this occurred “1 time about 8 months ago.”

Interview with witnesses stated that approximately three months ago, C1 entered a neighboring property by jumping the fence and was banging on the door and windows. A third image of C1 in a light grey sweatshirt, black pants, and white socks was provided as evidence of a separate occurrence. It is unclear what the date was for the elopement noted in the final image.
Page 2 (Continue on 9099-C)
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20251218100949
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/19/2025
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
During the visit LPA notes that the facility has 3 exit doors which all had door alarms, which were tested and found operational. The doors leading to the outside have a loud chime as well as a notification of which door opened. The alarm system panel that provides the notification is located between the laundry room and the kitchen. LPA along with QAS tested doors and the ability to hear the door alarm while the television was turned up loud (which staff admitted is common and LPA has observed in the past.) You can hear a faint chime, in the bedrooms, and can hear a very faint chime from the back office/medication area when the television volume is up loud, but you cannot hear what door is opened at all. Staff interviewed stated the day of the incident the television volume was up high due to C1 listening to their music.

Staff schedule shows two staff were working. The contract with Tri-County requires, “A minimum staffing ratio consistent with Title 17 California Code of Regulations is having one (1) staff present whenever one resident is in the home and a second staff present whenever a second resident is in the home during awake hours.” Three clients were home, the staffing minimum was within regulations.

In the presence of LPA and QAS, the administrator asked C1, how many times did you go into the neighbor yard yesterday? C1 held up 2 fingers and stated 2 times, Administrator repeated the question a second time, but with different wording and C1 replied the same “2 times”.

Based on staff notes, images, and interviews, the preponderance of evidence standard has been met that the client left the facility and was able to cross onto neighboring properties, at least one of those times it was without supervision until officers arrived, therefore the above allegation(s) is found to be SUBSTANTIATED.

Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC9099-D).
Page 3 (Continued 9099-C)
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 29-AS-20251218100949
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/19/2025
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
On the allegation: Facility did not follow reporting requirements

It was alleged that Client 1 (C1) left the facility property on at least two occasions, once on 12/17/25 and another approximately 3 – 8 months prior and entered the neighboring yard. Images discussed in the allegations provide there were two occurrences based on clients clothing and interview acknowledgements.

Title 22 regulations require that “Any unusual incident or client absence which threatens the physical or emotional health or safety of any client…” Shall be reported to licensing within the agency’s next working day, in addition a written report shall be submitted to licensing within seven days following the occurrence of such event.

The incident that occurred on 12/17/25 was reported by a witness to QAS Magana, who then contacted the administrator. The administrator stated they would provide a written report, which CCL received on 12/18/25. However, no verbal report was made to CCL within a day of the incident as required.

The prior incident approximately three to eight months ago was not reported to CCL either verbally or via an incident report. Administrator stated the prior report was not reported due to no law enforcement called, and they believed they had resolved the concern with the neighbor. Interviews with staff and witnesses state this type of incident also occurred over a year ago, but no incident reports with details of an elopement or attempted elopement are recorded with CCL for at least the last 2 years in regards to C1.

Based on interviews conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED.

Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC9099-D).

Exit interview conducted, appeal rights discussed, and a copy of this report issued.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20251218100949
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/09/2026
Section Cited
CCR
80061(b)(1)(E)
1
2
3
4
5
6
7
80061(b)(1)(E) Reporting Requirements (b)Upon the occurrence…of any of the events specified…below, a report shall be made to the licensing agency within… the next working day during its normal business hours…in addition, a written report…shall be submitted to the licensing agency within seven days following the occurrence of such event.
1
2
3
4
5
6
7
Based on the information obtained through interviews, and record reviews, the licensee failed to call and submit a written Incident report to the department when client wandered off facility property, which poses a potential health and safety risk to clients in care.
8
9
10
11
12
13
14
(1) Events reported shall include the following: (E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.
This requirement is not met as evidenced by:
8
9
10
11
12
13
14
Administrator has agreed to review regulations 80061 pertaining to reporting requirements and will send statement acknowledging the review as well as provide CCL with revised incident report for 12/17/25 and missing incident report from prior incident.
Type B
01/09/2026
Section Cited
CCR
80077.3(a)
1
2
3
4
5
6
7
Care for Clients who Lack Hazard Awareness or Impluse Control 80077.3(a)If a client requires protective supervision because of running/wandering away, supervision may be enhanced by fencing yards, using self-closing latches and gates, and installing operational bells, buzzers, or other auditory devices on exterior doors to alert staff when the door is opened. The fencing and devices must not substitute for appropriate staffing. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator agrees to provide CCL with elopement plans, as well as conduct staff training regarding the care and supervision for Clients who Lack Hazard Awareness or Impluse Control.
8
9
10
11
12
13
14
Based on the information obtained through interviews, and record reviews, a client was able to wander from the facility without supervision which poses a potential health and safety risk to clients in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5