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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850524
Report Date: 10/02/2025
Date Signed: 10/02/2025 05:02:05 PM

Document Has Been Signed on 10/02/2025 05:02 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:ROBLES RANCH MENTAL HEALTHFACILITY NUMBER:
405850524
ADMINISTRATOR/
DIRECTOR:		ASHLEY, CHEREEFACILITY TYPE:
772
ADDRESS:175 CRIPPLE CREEK ROADTELEPHONE:
(831) 245-7736
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY: 6CENSUS: 5DATE:
10/02/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Licensed Psychiatric Technician - Britney SmallTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
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At 9:00am, on 10/02/2025, Licensing Program Analyst (LPA) Haner-Tomasko arrived at the facility unannounced to conduct the annual facility inspection. LPA met with Licensed Psychiatric Technician (LPT) Britney Small, announced who he was and the reason for the visit. The Program Director Will Harris was contacted by phone, was unable to come to the facility, and gave permission for Britney to sign the report.

LPT and LPA conducted a full tour of the facility. This facility is a single story residential home that has four client bedrooms (two are dual occupancy), two full bathrooms (one is on-suite to one of the dual occupancy client bedrooms and one is for public/shared use), and there are two half bathrooms (one is public/shared use and the other for staff use only). There is a dining/activity room, living room with additional dining space and a fire place, a kitchen, a sun room and two office rooms. There was fresh fruit and snacks in the kitchen for clients to enjoy freely. The living room contains a fireplace that staff state is never used. Access to the laundry room and office rooms are through locked doors for client safety. The garage contains air hockey and billiards tables for client use. LPA noted that the backyard has seating and shade for clients and visitors. The backyard has an in ground pool and an above ground hot tub, both are covered for client safety. The facility has battery operated dual smoke/carbon monoxide detectors in each bedroom and hallways leading to bedrooms that are all working. LPA observed multiple fire extinguishers throughout the facility that were tagged current and in the green compression range, serviced on 04/03/2025. LPA tested facility hot water at 110*(f), within regulation temperatures 105*-120* (f). LPA observed at least 2-days of perishable and at least 7-days of nonperishable foods. LPA noted that the facility is clean with no obstructions in hallways, doorways or exits.



(Continued on LIC809-C)
NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Garrett Haner-Tomasko
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/02/2025
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 11
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: ROBLES RANCH MENTAL HEALTH
FACILITY NUMBER: 405850524
VISIT DATE: 10/02/2025
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During the facility tour LPA observed and photographed the following; at 9:55am two containers of Cascade dishwasher pods, Clorox disinfectant spray and Easy-Off oven cleaner below the kitchen sink; at 10:04am in the closet connected to the sun room eight bottles of laundry detergent each containing gallons of detergent; at 10:16am a plastic bin near the pool filtration system with various pool chemicals inside; and at 10:18am a closet attached to the accessory dwelling unit (ADU) with a variety of painting cans, hot tub chemicals and yard fertilizer, all unlocked and accessible to clients in care.

The ADU is located approximately 100 feet from the home and is only accessible to clients when staff are present. The ADU contains an activity room, therapy room, full bathroom, laundry area, and full kitchen. The full kitchen is used by staff.

Medications are locked in one of the office rooms. LPA conducted a sample medication audit and reviewed the facilities Centrally Stored Medication Records. LPA conducted a staff and resident file review, these files are stored digitally and were presented to the LPA on a laptop.

LPA and LPT conducted a review of the annual care tool modules.

Exit interview conducted, deficiency cited on LIC809-D pages, report signed, appeal rights and report provided to LPT Britney Small.
NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Garrett Haner-Tomasko
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/02/2025 05:02 PM - It Cannot Be Edited


Created By: Garrett Haner-Tomasko On 10/02/2025 at 03:54 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: ROBLES RANCH MENTAL HEALTH
FACILITY NUMBER: 405850524

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
81087(l)
Buildings and Grounds
(l) The licensee shall ensure that items which could pose a danger if readily available to clients, including but not limited to disinfectants, cleaning solutions and poisons are stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited when various disinfectants, cleaning solutions, and poisons were left accessible to clients in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/03/2025
Plan of Correction
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Most of the items were locked up during the LPA visit, the bin near the pool filter and ADU closet will be taken care of by 10/3/2025 and the program director will email LPA photos of these areas taken care of. Additionally, the program director will conduct a staff training regarding this regulation and email the training documents and signed staff roster to LPA on or before 10/9/2025. Program Director states they will also add checks to their weekly walk through of the facility.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:
Garrett Haner-Tomasko
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2025


LIC809 (FAS) - (06/04)
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