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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850480
Report Date: 09/04/2025
Date Signed: 09/04/2025 05:11:47 PM

Document Has Been Signed on 09/04/2025 05:11 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:OAKS AT PASO ROBLES, THEFACILITY NUMBER:
405850480
ADMINISTRATOR/
DIRECTOR:		CARL MEYERFACILITY TYPE:
740
ADDRESS:526 S RIVER ROADTELEPHONE:
(805) 239-5851
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY: 120CENSUS: 84DATE:
09/04/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Administrator - Carl MeyerTIME VISIT/
INSPECTION COMPLETED:
05:25 PM
NARRATIVE
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On 9/4/2025 at 10:00am Licensing Program Analyst (LPA) Haner-Tomasko arrived unannounced at the facility to conduct a Case Management – Incident visit. LPA met with Administrator Carl Meyer and explained the purpose of the visit.

On 9/2/2025 at 5:20pm Community Care Licensing (CCL) received an incident report via email from the facility stating that on 8/24/2025 at approximately 10:15am Resident #1 (R1) was reported missing. R1 was last seen walking out the back door by Staff #1 (S1). A staff-wide search was initiated and approximately 30 minutes later R1 was found at Kennedy Club Fitness.

LPA record review of R1’s LIC602A Physician’s Report indicates R1 is diagnosed with dementia and is not able to leave the facility unassisted. R1 resides in Compass Rose, the facilities memory care unit. LPA toured the memory care unit with Staff #2 (S2) ensuring the 4 doors in memory care with egress devices are functioning properly.

S1 is an agency staff brought in by the facility to cover open shifts. S1 was assigned to work in Compass Rose on 8/24/2025. Staff interviews reveal that S1 told other staff that R1 was trying to exit the egress door in the back of the unit leading to the parking lot. When S1 attempted to redirect R1, R1 began to hit S1 and S1 let R1 out of the facility through that door. Interviews revealed S1 changed their story multiple times and the timing of how long they let R1 out the door ranged from ten seconds to thirty minutes. At approximately 10:15am when S1 told other staff what happened the other staff notified lead staff on duty, Staff #3 (S3). S3 activated the facilities elopement protocol and a facility search began inside and outside the facility. S3 notified the administrator at 10:24am.

(Continued on LIC809-C)

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Garrett Haner-Tomasko
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2025
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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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: OAKS AT PASO ROBLES, THE
FACILITY NUMBER: 405850480
VISIT DATE: 09/04/2025
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S3 called R1's responsible person and left a voicemail. At approximately 10:45am Kennedy Club Fitness called the local police to assist R1. When the police arrived they called the facility to see if R1 lived here and the police returned R1 to the facility. Not long after R1's returned to the facility R1's responsible person arrived and facility staff reviewed the incident with them.

Administrator admitted no one notified the licensing agency Officer of the Day, by telephone, e-mail, fax, or hand-delivery no later than the next working day following the incident. The first notification to CCL was the emailed incident report dated 9/2/2025 at 5:20pm, nine days after the incident. LPA conducted a visit to the facility on 8/27/2025 and Administrator did not mention the elopement then. When asked why CCL had not been notified per Title 22 regulation the Administrator admitted he must have overlooked it.

Administrator and S2 state the four egress doors in Compass Rose are checked to ensure proper functioning monthly. Per facility protocol a monthly elopement drill is conducted with staff and record review shows the facility conducted drills following the incident and the previous two were conducted on 7/31/2025 and 6/26/2025. Record review of S1's training from the agency does not list any dementia training and the facility was unable to provide dementia training for S1 meeting the Health and Safety Code requirements.

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

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

DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/04/2025 05:11 PM - It Cannot Be Edited


Created By: Garrett Haner-Tomasko On 09/04/2025 at 04:15 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 PASO ROBLES, THE
FACILITY NUMBER: 405850480

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/18/2025
Section Cited
CCR
87705(e)(6)(B)

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Care of Persons with Dementia (e)Licensees that use delayed egress devices on exterior doors…shall meet the following…continuing requirements: (6)For each incident of elopement…the licensee shall report the incident to: (B)The licensing agency Officer of the Day…no later than the next working
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Administrator states they will train lead staff on reporting requiments as outlined in this regulation and email LPA with training documents and signed roster of staff trained on or before 9/18/2025.
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day following the incident... This requirement was not met as evidenced by:
Based on interview and record review, the licensee did not notify the licensing agency until nine days after the incident which poses a potential Health and Safety risk to persons in care.
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Type B
09/18/2025
Section Cited
HSC1569.625(b)(2)

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Staff training; legislative findings; contents
(b)(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626... This requirement was not met as evidenced by:
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Administrator states they will conduct an audit of agency staff used regularly to ensure they meet dementia training requirments and submit to the LPA via email the audit findings on or before 9/18/2025. Administrator also states moving forward they will ensure agency staff meet the dementia training.
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Based on interview and record review, the licensee did not ensure S1 was provided dementia training prior to working in the memory care unit which poses a potential Health and Safety risk to persons 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.
Kelly Burley
NAME OF LICENSING PROGRAM MANAGER:
Garrett Haner-Tomasko
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2025


LIC809 (FAS) - (06/04)
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