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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850036
Report Date: 12/20/2022
Date Signed: 12/20/2022 04:27:13 PM

Document Has Been Signed on 12/20/2022 04:27 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:PABLO LANE HOMEFACILITY NUMBER:
405850036
ADMINISTRATOR:SHANNON MACKENZIEFACILITY TYPE:
735
ADDRESS:340 PABLO LNTELEPHONE:
(805) 723-5126
CITY:NIPOMOSTATE: CAZIP CODE:
93444
CAPACITY: 4CENSUS: 3DATE:
12/20/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:33 PM
MET WITH:Rafael Mendoza, Back up to AdministratorTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) De Leon conducted a case management visit to the facility above due to a self reported incident at the facility. LPA met with back up to Administrator staff Rafael Mendoza. LPA explained the purpose of the visit.

LPA toured facility with staff and Tri-Counties Regional Center (TCRC) QA Miguel Magana.
Facility is clean , safe and sanitary. R1 eloped on 12/08/2022 early am. Facility staff last seen R1 at 3:45 AM. Facility staff on the AM shift went to wake R1 up prior to 6:00am to get R1 ready for work and it was discovered R1 had eloped out the bedroom window. Staff 1 (S1) attempted to call R1's cell phone. R1 was not answering phone when S1 was attempting to call R1. S1 tried to call R1 again at 10:15 AM and R1 answered, R1 stated R1 was in Texas and was going to go to Miami Florida for a few weeks and will return to the facility but did not give an exact date and time of return. R1 does take medications. R1 has been without medications while gone. R1 has not returned to the facility as of 12/20/2022.

LPA has requested records: LIC. 602 report, IPP for TCRC, incident report for R1 Elopement, R1's Needs/Services plan, R1's Behavioral Report and R1's Individual Service Plan. Staff provided all documents except R1's LIC. 602 and Needs and Services Plan as staff was unable to locate at the time of visit and will provide to LPA timely.

Based on the TCRC IPP R1 is supervised at work and at home.

Exit interview conducted, deficiency cited, copy of report and appeal rights emailed to the Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2022
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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Document Has Been Signed on 12/20/2022 04:27 PM - It Cannot Be Edited


Created By: Rachael De Leon On 12/20/2022 at 03:51 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: 12/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/21/2022
Section Cited
CCR
80078(a)

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(a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not met as evidenced by:
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Facility agreed to contact Smith Alarms to see if facility can get alarms on the screens of the windows and if not able to the facility will purchase alarms and install themselves.
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Based on incident report the Licensee failed to comply with the regualtion above R1 was able to elope un-detected which poses an immediate health and safety risk to residents in care.
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Facility will implement 30 minute checks on R1's return.

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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.
SUPERVISOR'S NAME:Kelly Burley
LICENSING EVALUATOR NAME:Rachael De Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2022


LIC809 (FAS) - (06/04)
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