405809547-2-26-2026-29-AS-KBUY-DRQ2N7-20260227163217

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405809547
Report Date: 02/26/2026
Date Signed: 02/26/2026 02:14:48 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
06/26/2025 and conducted by Evaluator Melisa Rankin

COMPLAINT CONTROL NUMBER: 29-AS-20250626082420

FACILITY NAME:	OAKS AT NIPOMO, THE		FACILITY NUMBER:	405809547
ADMINISTRATOR:	RONALD C. FREEMAN		FACILITY TYPE:	740
ADDRESS:	177 MARY AVENUE		TELEPHONE:	(805) 723-5206
CITY:	NIPOMO	STATE: CA	ZIP CODE:	93444
CAPACITY:	122	CENSUS: 96	DATE:	02/26/2026
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Ron Freeman		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff do not follow reporting requirements
Facility has insufficient staffing to meet the needs of the residents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rankin conducted a subsequent complaint visit to issue final findings on this investigation. LPA met with Ron Freeman and explained the purpose of the visit. During the investigation, LPA conducted an initial visit 7/2/25 where LPA conducted interview with administrator and staff and obtained relevant documents. LPA conducted additional interviews with staff and residents during visits on 7/16/25, 10/1/25, 11/21/25, and 12/8/25.

On the allegation: Staff do not follow reporting requirements
It was alleged there had been 4 - 5 falls in June at the facility, and staff had been instructed by a manager not to report any of the falls to licensing. Alleged the falls were in both assisted living and memory care.
Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20250626082420

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: OAKS AT NIPOMO, THE	FACILITY NUMBER: 405809547
	VISIT DATE: 02/26/2026

NARRATIVE

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On 07/02/25, LPA collected electronic incident reports from the facility which are documented in the facility’s electronic health record (EHR) system. Dates of reports reviewed were from 01/02/25 to 07/02/25. LPA reviewed a total of 133 incident reports from the EHR. Based on this review and comparison to reported incidents submitted to the Community Care Licensing (CCL), LPA observed that falls described as having no visible injuries, minor skin tears, or no complaints of pain were not submitted to the Department. However, all serious incidents involving residents—such as falls resulting in pain, head injuries, or requiring transfer for medical attention—were reported to the Department prior to this complaint. While some fall incidents were not provided to licensing, regulations require that “a written report shall be submitted to the licensing agency… of any of the events specified in (A) through (D)… (A) Death… (B) Any serious injury… (D) Any incident which threatens the welfare, safety or health of any resident…”

LPA interviewed staff on 7/2/25, 11/21/25, and 12/8/25 there were no reports of management directing staff not to report an incident. Of those interviewed all stated, they have no knowledge of management directing staff not to report incidents, falls, or injuries.

Based on records, interviews, and observations there is not a preponderance of evidence to prove the above allegations did or did not occur therefore the allegations are UNSUBSTANTIATED at this time.

On the allegation: Facility has insufficient staffing to meet the needs of the residents

It was alleged that the facility has insufficient staffing to meet the needs of residents and that managers have recently covered a 24-hour shift.

LPA conducted eight staff interviews and five resident interviews, and reviewed facility records. On 07/01/25, a former staff member reported that at times only one caregiver was present in Memory Care, although two caregivers and a medication technician are expected. On 07/02/25, the administrator acknowledged being down six to ten staff but stated shifts were covered by agency caregivers, managers, and current staff, and that the facility maintained required staffing ratios. Continue on 9099-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2026

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20250626082420

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: OAKS AT NIPOMO, THE	FACILITY NUMBER: 405809547
	VISIT DATE: 02/26/2026

NARRATIVE

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During the same visit, staff confirmed at least two caregivers per shift and denied managers working full 24-hour shifts. LPA reviewed schedules and timecards which showed that consistently there are at least two caregivers, if not three in the memory care unit and assisted living unit during daytime shifts, including a medication technician for each side and at minimum three total caregivers and one medication technician to cover the full facility during the NOC shifts.

Resident interviews conducted on 7/2/25, 7/16/25, and 11/21/25, revealed occasional comments from residents indicating that staff claimed to be short-staffed when delays occurred; however, these statements were inconsistent and not corroborated by other evidence. Residents acknowledged the use of agency staff and noted that turnover affects consistency, but independent residents reported that there have generally been enough staff to meet their needs. Some residents and staff agreed that evening shifts are busier due to more residents requiring cognitive support.

While some delays were reported, there is insufficient evidence to conclude the facility failed to meet care and supervision requirements during the time frame leading up to this complaint. Records indicate the facility has not violated staffing regulations during the time frame of this complaint.

Based on interviews and record reviews, there is insufficient evidence to support the allegation that the facility is not adequately staffed to meet resident needs. While the allegations may or may not have occurred, the allegation is deemed UNSUBSTANTIATED at this time.

A copy of this report was printed and provided to the administrator.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2026

LIC9099 (FAS) - (06/04)

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