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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405801714
Report Date: 01/09/2026
Date Signed: 01/09/2026 01:55:20 PM

Substantiated


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
10/15/2025 and conducted by Evaluator Melisa Rankin
COMPLAINT CONTROL NUMBER: 29-AS-20251015073453
FACILITY NAME:BAUER RESIDENTIAL-NIPOMOFACILITY NUMBER:
405801714
ADMINISTRATOR:SHIRLET HALLIDAYFACILITY TYPE:
735
ADDRESS:890 PROSPERITY WAYTELEPHONE:
(805) 929-5758
CITY:NIPOMOSTATE: CAZIP CODE:
93444
CAPACITY:4CENSUS: 3DATE:
01/09/2026
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Shirlet HallidayTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Staff violated resident personal rights
Staff did not seek medical attention for Client in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rankin conducted a subsequent complaint visit to issue final findings on this investigation. During this visit the LPA also completed the required annual visit. LPA met with Shirlet Halliday and explained the purpose of the visit. During the investigation, LPA conducted an initial visit on 10/16/2025, where LPA conducted interviews with administrator. During the investigation prior interviews related to an incident involving the care of client 1 (C1) were reviewed. Three Collateral visits were done on 10/16/25, 11/04/25, and 12/17/25. A phone interview with an administrator/supervisor of staff who work with C1 was done on 12/23/25.

On the allegation: Staff did not seek medical attention for Client in care
It was alleged that staff failed to obtain medical care for C1 after an off-duty, unauthorized staff member Staff 1 (S1) punched C1 in the head and stomach. Interviews and records confirmed that C1 was punched three times in the head and once in the stomach after midnight on 8/24/25. Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2026
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 4
Control Number 29-AS-20251015073453
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: BAUER RESIDENTIAL-NIPOMO
FACILITY NUMBER: 405801714
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/12/2026
Section Cited
CCR
80075(a)
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80075 Health Related Services(a)The licensee shall ensure that each client receives necessary first aid and other needed medical… services… This requirement is not met as evidenced by:
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The Administrator has agreed to do the following:
Review Regulation 80075 and submit a Statement by 1/12/26. The Statement will include: How the facility will maintain compliance with Regulation 80075(a).
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Based on interviews and record review, the licensee did not comply with the section cited above when a client was physically abused by an off-duty, unauthorized staff, who punched client in the head 3 times and in the stomach once, and the facility did not seek medical attention, which posed an immediate health and safety risk to the client in care.
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Procedures to ensure prompt medical attention is provided following any physical injuries and steps to guarantee timely medical care when a resident exhibits symptoms of discomfort or health concerns.
The Administrator will ensure all staff are trained on these procedures and that documentation of compliance is maintained in the facility records.
The Administrator will ensure all staff are trained on these procedures and that documentation of compliance is maintained in the facility records.
Type B
01/09/2026
Section Cited
CCR
80072(a)
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80072 Personal Rights…each client shall have personal rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons.
This requirement is not met as evidenced by:
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Facility completed personal right training on 9/17/25, Facility will have each staff member re-sign statement regarding appropriate use of photography and videos.
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Based on interviews and documentation, the licensee did not comply with the section cited above when a client was photographed in a recliner naked, with feces and the photograph was provided to a family member, which posed a personal rights violation to clients 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.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 29-AS-20251015073453
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: BAUER RESIDENTIAL-NIPOMO
FACILITY NUMBER: 405801714
VISIT DATE: 01/09/2026
NARRATIVE
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A Case Management visit was conducted on 8/29/25 regarding this incident and citations were given. This new allegation is to investigate additional concerns regarding C1’s care. Following the incident, records state that Staff 4 (S4), and the administrator assessed C1 and determined that no injuries were present, so C1 was not taken to the hospital.

Records state that C1 has a history of seizures, one occurring on 5/8/25 per an incident report provided to Community Care Licensing. Despite this known medical history, staff did not arrange for a medical evaluation immediately after or in the following days of the incident on 8/24/25.

During the investigation, an additional incident was identified involving Client 2 (C2). Documentation shows that C2 developed skin rash on their left arm, it was first documented/noticed on 09/16/25 on the daily progress notes, it was also reported via an incident report by the facility, stating first noticed on 9/16/25. Documents state that the day it was discovered administrator tried to schedule an appointment, but none were available until an original appointment date of 10/8/25. Interview with administrator, the facility began treating the rash with a first aid ointment. The daily progress notes show 3 areas of concern on C2’s left arm, C2 continued to pick at the affected areas over the next 9 days, medical treatment was obtained on 09/25/25. It was documented on an incident report that doctor stated C2 was picking at the skin due to itching.

Due to the behaviors and service plans of clients in care, continual items that cause agitation such as picking or itching can lead to behaviors and injuries. Clients in care of facility cannot all verbalize their injuries or pain, therefore the need to have a medical professional examine them after incidents is necessary as the facility is not a medical facility and cannot determine those conditions.

Based on interviews and records obtained there is sufficient evidence that the allegations that the facility did not seek timely medical attention or provide appropriate follow-up care placed residents at risk and therefore is substantiated.
Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D). Continued on 9099-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 29-AS-20251015073453
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: BAUER RESIDENTIAL-NIPOMO
FACILITY NUMBER: 405801714
VISIT DATE: 01/09/2026
NARRATIVE
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On the allegation: Staff violated resident personal rights
It was alleged that staff at the current and previous homes under this licensee took inappropriate images and videos of C1, it was also alleged that abuse at prior facilities was conducted. During the investigation prior interviews done in September and October of 2025 related to an incident involving the care of client 1 (C1) were reviewed. Five interviews conducted for prior complaint # 29-AS-20250820071748 were relevant to this complaint. Three Collateral visits were done on 10/16/25, 11/04/25, and 12/17/25 in which 5 current or prior staff were interviewed. A phone interview with an administrator/supervisor of staff who work with C1 was done on 12/23/25. Staff interviewed have worked in and around C1 or work with staff who work with C1. None of the staff admitted to observing any abuse or to possessing, viewing, or sharing images of C1. All staff have stated they have not heard of other staff who have possessed or shared inappropriate videos or images of any client.

LPA interviewed Witness 1 (W1) identified by C1’s family as the individual who informed them about the images. W1 denied seeing or possessing any images but admitted to LPA and Quality Assurance Specialist with Tri-County Regional Center during an interview on 10/16/25 that they had heard of staff at Bauer facilities taking photos and videos. LPA did a follow-up visit with W1 on 12/17/25 and again inquired about the allegations in which W1 stated that Staff 2 (S2) who works at the facility with C1 had told W1 about the incidents. LPA and TCRC on 9/10/25, during the investigation for complaint # 29-AS-20250820071748 had interviewed S2, who was asked about abuses taking place and about video or photographs of C1, during interview the staff member stated they did not have and have not seen any video or photographs, S2 claimed that they had heard C1 was tied up, but had not witnessed it.

During the investigation, LPA was provided with an image of C1 sitting naked in a recliner, with feces visible between their legs. The image was sent to Family 1 (F1) in the context of accompanying text messages. C1 is mostly non-verbal and due to their disability is unable to provide consent for this image.

Based on documentation obtained during the investigation, it was determined that staff violated C1’s personal rights by taking and sharing an inappropriate image. There is no evidence at this time that multiple incidents involving inappropriate videos or images occurred, nor that any abuse was conducted. However, due to the one image being unnecessarily shared and in violation of C1’s personal rights, the allegation is Substantiated.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D).

Exit interview conducted, copy of appeal rights and report printed for administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 4