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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801971
Report Date: 07/16/2025
Date Signed: 07/16/2025 02:31:18 PM

Document Has Been Signed on 07/16/2025 02:31 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:PASO ROBLES SENIOR LIVINGFACILITY NUMBER:
405801971
ADMINISTRATOR/
DIRECTOR:		ERIC BUNTEFACILITY TYPE:
740
ADDRESS:380 SCOTT STREETTELEPHONE:
(805) 227-4383
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY: 6CENSUS: 5DATE:
07/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Licensee/Administrator - Eric BunteTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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 At 09:15am, on 07/16/2025, Licensing Program Analyst (LPA) Haner-Tomasko arrived at the facility unannounced to conduct the annual facility inspection. LPA met with Licensee/Administrator Eric Bunte, announced who he was and the reason for the visit.

Licensee/Administrator and LPA conducted a full tour of the facility. This facility is a residential home with 2 dual occupancy and 2 single occupancy resident bedrooms, one full shared bathroom and one half shared bathroom. On the second floor is a live-in staff bedroom with full staff bathroom. There is a living room with dining space, a kitchen and office area. While touring the kitchen LPA noted fresh fruit and snacks in the kitchen for residents to enjoy. At 9:42am in the kitchen LPA noted over fifteen prescription and non-prescription medications in four unlocked cabinets and a bottle of liquid lorazepam unlocked in the kitchen refrigerator, all accessible to residents in care. Access to the laundry room is in the hallway. The garage containing cleaning supplies and laundry detergent is through a locked door for resident safety. LPA noted that the backyard has seating and shade for residents and visitors. While touring the backyard at 10:15am LPA noted nine bottles of chemicals (including bleach and Cascade dish washing soap) unlocked and accessible to residents in care. The facility has wired smoke detectors in each bedroom and hallway leading to a bedroom that are all working, the carbon monoxide detector is in the hallway and functioning normally. LPA observed a fire extinguisher near the office area that was tagged current and in the green compression range, purchased on 08/14/2024. LPA tested facility hot water at 110.4*(f), within regulation temperatures 105*-120* (f). LPA observed at least 2-days of perishable and at least 7-days of nonperishable foods.

(Continued on LIC809-C)

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Garrett Haner-Tomasko
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/16/2025
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 8
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: PASO ROBLES SENIOR LIVING
FACILITY NUMBER: 405801971
VISIT DATE: 07/16/2025
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LPA noted that the facility has no obstructions in hallways, doorways or exits. Medications, staff and resident records are locked in a cabinet in the hallway. LPA conducted a sample medication audit and reviewed the facilities Centrally Stored Medication Records, finding no violations. LPA conducted a staff and resident file review.

LPA and Licensee/Administrator conducted a review of the annual care tool modules. Deficiencies were cited at this time.

Exit interview, report signed, deficiencies cited on LIC809-D, appeal rights, and report provided.

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Garrett Haner-Tomasko
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/16/2025 02:31 PM - It Cannot Be Edited


Created By: Garrett Haner-Tomasko On 07/16/2025 at 02:05 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: PASO ROBLES SENIOR LIVING
FACILITY NUMBER: 405801971

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above when LPA noted over fifteen prescription and non-prescription medications in four unlocked kitchen cabinets, a bottle of liquid lorazepam unlocked in the kitchen refrigerator and nine bottles of chemicals (including bleach and Cascade dish washing soap) unlocked and accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/17/2025
Plan of Correction
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Licensee will email LPA a statement of understanding of this regulation and how the facility will work to comply with the cited regulation by 7/17/2025. Additionally Licensee will assign all staff training or conduct the training on the regulation and submit the training material and signed staff roster to LPA on or before 7/30/2025. Licensee stated they would conduct more frequent checks 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: 07/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2025


LIC809 (FAS) - (06/04)
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