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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405809547
Report Date: 07/09/2021
Date Signed: 07/09/2021 04:21:52 PM

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: 78DATE:
07/09/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Donahue Vanderhider and Rachel TanakaTIME COMPLETED:
03:48 PM
NARRATIVE
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Licensing Program Analyst (LPA) De Leon conducted a Case Management visit to the facility regarding a self reported incident report. LPA was greeted by Administrator Donahue Vanderhider and LPA explained the purpose of the visit.

LPA requested the following records:
Staff Roster for 06/2019, Resident Roster for 06/2019, copy of Resident 1's (R1) LIC. 602 physicians report, Staff notes on R1 for 06/16/2021, Appraisal Needs and Services plan for R1, Doctor order for 2 person assist or facility documentation of required two person assist, copy of sign posted regarding required 2 person assist.

Administrator needed to leave facility and provided LPA with a LIC. 308 Designation of Facility Responsibility designating Rachel Tanaka to complete visit, provide LPA with documentation requested and sign report.

LPA reviewed incident report, facility records and R1's resident file. Staff failed to provide a required 2 person assist when transferring resident, resident fell and required an emergency room visit for head injury.

Exit interview completed, deficiency cited, copy of report emailed to Administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/16/2021
Section Cited

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...(3)Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents. This requirement was not met as evidenced by:
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Based on record review the Licnesee did not comply as staff failed to provide a required 2 person assist and resident fell and went to ER which poses a potential Health and safety risk to residents 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 BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:
DATE: 07/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2021
LIC809 (FAS) - (06/04)
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