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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405809547
Report Date: 02/27/2025
Date Signed: 02/27/2025 02:03:26 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/03/2025 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20250203141805
FACILITY NAME:OAKS AT NIPOMO, THEFACILITY NUMBER:
405809547
ADMINISTRATOR:RONALD C. FREEMANFACILITY TYPE:
740
ADDRESS:177 MARY AVENUETELEPHONE:
(805) 723-5206
CITY:NIPOMOSTATE: CAZIP CODE:
93444
CAPACITY:122CENSUS: DATE:
02/27/2025
UNANNOUNCEDTIME BEGAN:
01:31 PM
MET WITH:TIME COMPLETED:
02:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff handle resident in a rough manner.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above. LPA met with Administrator Ronald Freeman and explained the purpose of the visit.

LPA De Leon conducted the initial 10-day complaint visit, toured facility memory care unit, observed lunch service, requested records and interviewed staff at 10:45am, 11:00am, 12:40pm, 1:10pm, 1:20pm, 2:52pm and 3:11pm and interviewed residents at 11:20am, 11:45am, 2:00p and 2:20pm.
LPA conducted a subsequnet complaint visit on 02/27/2025 and interviewed additonal staff from 10:45am-1:30pm.
On the allegation: Facility staff handle resident in a rough manner. LPA De Leon interviewed staff, residents, and reviewed facility memory care records for staff and residents.
Staff interviews revealed 1 out of 7 staff heard about an incident with a new NOC Caregiver Staff handling a resident roughly.
Continued 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 29-AS-20250203141805
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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, THE
FACILITY NUMBER: 405809547
VISIT DATE: 02/27/2025
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
26
27
28
29
30
31
32
LPA requested and reviewed disciplinary records for Memory care staff caregivers which revealed a Corrective Counseling Documentation record for Staff 1 (S1) on 01/21/2025. S1 required corrective counseling for several incidents on this form, with one being during S1’s training period, it was reported that S1 spoke harshly and treated a resident roughly with taking a residents blood pressure reading, then on 01/07/2025 there was another incident regarding a resident 1 (R1) being agitated and would not return to the R1’s room, S1 was advised by another staff not to provoke the R1 any further, S1 went against the advice given and took R1 back to the R1’s room while in the room it was claimed the R1 hit S1 in the chest, S1 said S1 had to grab R1 and sit R1 down in a chair in R1’s room. S1 was questioned about the incident by another staff and S1 changed S1’s story. S1 was advised to write an incident report but wrote a note instead, R1 was assessed after the incident and new skin tears were observed on R1. Management had concerns with S1 so S1’s probationary period has been extended to 03/15/2025 although S1 has violated the Facilities prohibited conduct when S1 was caring for a resident in an unprofessional, rough, or demeaning manner on two separate incidents. S1 had other counseling incidents on the same form but none of those other incidents involved residents. Based on the evidence this allegation is deemed Substantiated at this time.

Exit interview conducted, deficiency cited, copy of report and appeal rights printed for Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20250203141805
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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, THE
FACILITY NUMBER: 405809547
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/27/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/28/2025
Section Cited
CCR
87468.1(a)(3)
1
2
3
4
5
6
7
(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Administrator agreed to re-train S1 in facility policy and procedures for abuse, reporting, and personal rights of residents in care and provide proof of trianing to CCL.
8
9
10
11
12
13
14
Based on record review the Licensee did not comply with the regulation above, S1 handled R1 roughly causing skin tears and making R1 return to R1's room against R1's will which is an immediate health, saftey and personal rights risk to residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/03/2025 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20250203141805

FACILITY NAME:OAKS AT NIPOMO, THEFACILITY NUMBER:
405809547
ADMINISTRATOR:RONALD C. FREEMANFACILITY TYPE:
740
ADDRESS:177 MARY AVENUETELEPHONE:
(805) 723-5206
CITY:NIPOMOSTATE: CAZIP CODE:
93444
CAPACITY:122CENSUS: DATE:
02/27/2025
UNANNOUNCEDTIME BEGAN:
01:31 PM
MET WITH:Ronald Freeman, AdministratorTIME COMPLETED:
02:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff did not change resident in a timely manner.
Facility staff does not provide adequate food portions to residents.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above. LPA met with Administrator Ronald Freeman and explained the purpose of the visit.

LPA De Leon conducted the initial 10-day complaint visit, toured facility memory care unit, observed lunch service, requested records and interviewed staff at 10:45am, 11:00am, 12:40pm, 1:10pm, 1:20pm, 2:52pm and 3:11pm and interviewed residents at 11:20am, 11:45am, 2:00p and 2:20pm.
LPA conducted a subsequnet complaint visit on 02/27/2025 and interviewed additonal staff from 10:45am-1:30pm.
On the allegation: Facility staff did not change resident in a timely manner. Facility staff interviews revealed some residents did have rashes in the memory care unit, residents that have rashes have doctor orders for creams and/or powders to help, the residents are changed every two hours on rounds or when needed to avoid the residents being wet for a prolonged periods, residents have the right to refuse services and if residents refuse services it is documented. Based on the evidence this allegation is Unsubstantiated at this time. Continued 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20250203141805
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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, THE
FACILITY NUMBER: 405809547
VISIT DATE: 02/27/2025
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
26
27
28
29
30
31
32
On the allegation: Facility staff does not provide adequate food portions to residents. The facility has a Main Commercial Kitchen in the Assisted Living portion of the building, the cook prepares the food and portions the food into large servings containers with lids in warming trays and sent to the memory care kitchen to be plated and served. The portion of food is based on the memory care census of residents. LPA observed the lunch meal served in the memory care unit as the complaint was specific to the Memory Care Unit (MC). LPA observed the lunch meal to be a ½ of a large burrito with sides of spanish rice and black beans, which looked like an adequate serving for a lunch meal. LPA did not observe any substitution of food for this meal in the MC kitchen, staff interviews indicated if someone didn’t want to eat what was served, staff can call to the dining room and get something else for a resident. LPA interviewed a witness 1 (W1) that indicated the portion size was adequate for the lunch meal, but no other substitutions seemed to be offered and the resident that W1 was visiting did not like or want to eat the black beans and would have preferred to eat a taco over a burrito, just easier for the resident to eat on own. LPA observed several residents eating the meal served, many ate most of the serving, didn’t observe anyone getting more food, seen several residents still sitting with half to full plates. W1 visits often and feels some residents need help eating and may not be getting that and some may be slow eaters and just take longer to eat. Staff interviews revealed they learn the residents likes and dislikes and will always get residents another meal if residents do not like the meal being served, if staff see someone eat less at breakfast they offer them more at lunch, the staff feel the portions are good size and that the MC kitchen always has a lot of leftovers. LPA observed several portions of food remaining after service was done and most residents had left the dining room area. Based on the lack of evidence this allegation is Unsubstantiated at this time.

Exit interview conducted and copy of report printed for Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5