405802253-1-26-2026-29-AS-GHTO-DQPPVC-20260126103855

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405802253
Report Date: 01/26/2026
Date Signed: 01/26/2026 10:39:02 AM

Document Has Been Signed on 01/26/2026 10:39 AM - 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:	BOB & CORKY'S CARE HOME IV		FACILITY NUMBER:	405802253
ADMINISTRATOR/ DIRECTOR:	DEBORAH COLE		FACILITY TYPE:	740
ADDRESS:	2525 AUGUSTA STREET		TELEPHONE:	(805) 439-3301
CITY:	SAN LUIS OBISPO	STATE: CA	ZIP CODE:	93401
CAPACITY: 6		CENSUS: 6	DATE:	01/26/2026
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	Administrator - Deborah Cole		TIME VISIT/ INSPECTION COMPLETED:	11:00 AM

NARRATIVE

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Licensing Program Analyst (LPA) Garrett Haner-Tomasko conducted a case management – incident visit to the facility along with personnel from Tri-Counties Regional Center (TCRC). LPA met with Administrator Deborah Cole and explained the purpose of the visit.

The Department received an incident report regarding a resident found on the ground in the backyard of the facility by staff. The Department also received photos of injuries that occurred to the resident’s face, elbow, knee and toes possibly due to this incident. During the visit, LPA and TCRC personnel checked on the resident’s wellness and toured the facility. Staff are not sure how the resident got outside, the resident was last checked at 3:40am in their room and at approximately 6:50am during shift change the resident was found outside in the backyard. Staff check on residents approximately every two hours throughout the night and state this resident does often ask staff to leave their room when they do their checks. After the incident, staff implemented additional precautions for the resident’s safety; placing a floor mat with alarm next to the bed and a pressure bed alarm to alert staff of the residents attempt to get out of bed without assistance between staff checks, conducting extra checks on the resident, and a meeting was conducted between TCRC personnel, the facility administrator and residents responsible person to discuss additional safety measures. The resident states they like this facility and the staff that care for them. They do not recall falling recently.

LPA and TCRC personnel provided technical assistance to the facility administrator and licensee on reporting requirements and additional safety measures that can be taken to keep the resident safe. During this visit no deficiencies were cited, but the LPA may return at a later date if citations are warranted.

Exit interview conducted, report signed, and report provided to the Administrator.

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Garrett Haner-Tomasko
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/26/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2026

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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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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