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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405809547
Report Date: 09/16/2021
Date Signed: 09/16/2021 03:58:16 PM

Document Has Been Signed on 09/16/2021 03:58 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:OAKS AT NIPOMO, THEFACILITY NUMBER:
405809547
ADMINISTRATOR:DONAHUE VANDERHIDERFACILITY TYPE:
740
ADDRESS:177 MARY AVENUETELEPHONE:
(805) 723-5206
CITY:NIPOMOSTATE: CAZIP CODE:
93444
CAPACITY: 122CENSUS: 77DATE:
09/16/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:02 PM
MET WITH:Rachel Tanaka, Business Office DirectorTIME COMPLETED:
04:03 PM
NARRATIVE
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Licensing Program Analyst (LPA) De Leon conducted a case management incident visit to the facility above. LPA met with Business Office Director Rachel Tanaka and explained the purpose of the visit.

It was reported to Community Care Licensing (CCL) that the facility had an incident on 08/31/2021 regarding a resident that was taken to the ER. CCL did not receive any incident report from the facility regarding such an incident for that date. Based on information received at the visit to the facility, the facility staff/Administrator failed to report the incident to CCL.

Exit interview conducted, deficiency cited, copy of report and appeal rights emailed to Licensee/Administrator.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2021
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 09/16/2021 03:58 PM - It Cannot Be Edited


Created By: Rachael De Leon On 09/16/2021 at 03:46 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: OAKS AT NIPOMO, THE
FACILITY NUMBER: 405809547

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/20/2021
Section Cited
CCR
87211(a)(1)

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...(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence...This requirement was not met as evidenced by:
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Administrator agreed to submit incident report to CCL for the 08/31/21 incident and will train reporting staff on regulation 87211, submit report, trianing and staff signatures to CCL.
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Based on documentation and obeservation the Licensee did not comply with regualtion as the facility did not report a reisdent incident on 08/31/2021 which poses a potential safety risk to reisdent in care.
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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: 09/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2021


LIC809 (FAS) - (06/04)
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