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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850036
Report Date: 12/19/2025
Date Signed: 12/19/2025 03:40:53 PM

Document Has Been Signed on 12/19/2025 03:40 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:
12/19/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:32 PM
MET WITH:Pamela HolcombeTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Melisa Rankin along with Tri-Counties Regional Center (TCRC) Quality Assurance Specialist (QAS) Miquel Magana conducted an unannounced complaint visit which prompted a Case Management - Deficiencies inspection due to deficiencies observed during the investigation for Complaint control # 29-AS-20251218100949. LPA met with Administrator Pamela Holcombe and explained the reason for the visit.

During the investigation, LPA and QAS toured the facility and checked medication cabinet and found it to be unlocked. LPA photographed the medication cabinet drawer they were able to open, which poses a risk to the health and safety of residents as medications must be kept inaccessible to unauthorized individuals.

LPA also toured the facility to review previously discussed areas of concern. In Bathroom 2, LPA observed toilet paper under the bathroom cabinet that had been chewed by a rodent, along with what appeared to be mice droppings inside the cabinet. This issue had been previously discussed during an annual visit, and a prior image was taken at that time. Additionally, LPA observed that the bathroom door and light switch had a reddish-brown colored substance. These same areas were noted during the annual visit, and documented with images; however, the same substances were still present and were compared to prior images. The smudges were the same and in the same location.

Based on current observations and prior documentation, the facility is being cited for deficiencies related to cleanliness and sanitation and safeguarding of medications. These conditions pose potential health and safety risks to residents and indicate that corrective measures previously discussed were not adequately implemented.

Copy of report printed, appeal rights discussed.

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Melisa Rankin
LICENSING PROGRAM ANALYST 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.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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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Document Has Been Signed on 12/19/2025 03:40 PM - It Cannot Be Edited


Created By: Melisa Rankin On 12/19/2025 at 03:02 PM
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: 12/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/22/2025
Section Cited
CCR
80087(a)

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80087 Buildings and Grounds (a)The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
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Facility needs to clean areas discussed and ensure there is pest controll maintained.
Completed during time of visit, areas were cleaned and Pest control came to check traps and is scheduled to return every other month, but will monitor if needed to do monthly.
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Based on observation and prior photographs review, the facility failed to clean up rodient dropping and as well as clean what appeared to be bodily fluid on the bathroom door and light switch which poses a potential health and safety risk to clients in care.
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Type B
12/31/2025
Section Cited
CCR80075(k)(1)

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80075 Health Related Services (k) The following requirements shall apply to medications which are centrally stored:(1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
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Administrator will conduct a medicaiton training and provide LPA with sign in sheets and copies of the training by 12/31/25.
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Based observation the facility failed to lock medications which poses a potential health and safety risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kelly Burley
NAME OF LICENSING PROGRAM MANAGER:
Melisa Rankin
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST 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


LIC809 (FAS) - (06/04)
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