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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425800121
Report Date: 12/04/2025
Date Signed: 12/04/2025 03:40:10 PM

Document Has Been Signed on 12/04/2025 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:TOBY RANCH RESIDENCEFACILITY NUMBER:
425800121
ADMINISTRATOR/
DIRECTOR:		HELEN SAN ANTONIO98FACILITY TYPE:
735
ADDRESS:532 CABO SAN LUCAS CIRCLETELEPHONE:
(805) 349-8215
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY: 6CENSUS: 6DATE:
12/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:20 AM
MET WITH:Administrator, Hellen San AntonioTIME VISIT/
INSPECTION COMPLETED:
11:59 AM
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
 At 8:15am on 12/04/2025 Licensing Program Analyst (LPA) Jeffries arrived at the facility unannounced to conduct the Required Annual visit. LPA met with Administrator Helen San Antonio. The facility's last annual was conducted on 01/15/2025.

Administrator and LPA conducted physical tour of the facility. This facility has 4 bedrooms and three bathrooms, with a kitchenette dining room and small living room. There is a fenced backyard that has seating and a large pergola for shade for clients to have outdoor activities and visitations. Larger home also attached to clients facility and meals are prepared in the larger home. Smoke detectors and carbon monoxide detectors functioning. Fire extinguisher was fully charged. Facility temperature was 70 degrees F. Hot water temperature tested and read in regulation range of 105*-120*(f).. Residents’ rooms are appropriately furnished with adequate lighting. LPA observed an adequate amount of perishable and non-perishable food. Food is stored in proper containers in the refrigerator and freezer. A written disaster and mass casualty plan is readily available. Administrator is on the premises an adequate amount of hours to manage and oversee the facility. Disaster drills are conducted quarterly and documented.. LPAs conduced a cursory review of medications. Medications are stored in a locked cabinet. There is a signed and dated order from a physician for prescription and PRN medication. LPA observed the Centrally Stored Medication (CSMR) and medications are given per physician's orders. LPAs reviewed client and staff files. All client files reviewed have current physicians report, current needs and services plans and admission agreements. Staff files reviewed had current first aid certificates, criminal record statements and adequate training hours. LPA reviewed Emergency Disaster Plan and Infection Control Plan. Administrator and LPA conducted a full review of annual care tools modules. LPA noted at this time there were no citations issued on this annual facility inspection.Exit interview, no deficiencies cited, report given.

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Mark Jeffries
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2025
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 6
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)
Page: 2 of 6