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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405809547
Report Date: 07/20/2023
Date Signed: 07/21/2023 08:19:00 AM


Document Has Been Signed on 07/21/2023 08:19 AM - It Cannot Be Edited

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:TRACY S. FLAHERTYFACILITY TYPE:
740
ADDRESS:177 MARY AVENUETELEPHONE:
(805) 723-5206
CITY:NIPOMOSTATE: CAZIP CODE:
93444
CAPACITY:122CENSUS: 100DATE:
07/20/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Ronald Freeman, AdministratorTIME COMPLETED:
05:20 PM
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Licensing Program Analyst (LPA) De Leon arrived at 10:15 am to conducted a 1 year annual visit to the facility above. LPA met Administrator Ronald Freeman and explained the purpose of the visit.

A tour of the Compass Rose Memory Care kitchen/dining area was compelted and LPA observed CCL poster in the entry way. LPA observed the CCL poster in the front entry of the facility.

LPA reviewed Staff Roster and Guardian Roster for staff associations, clearances and exemptions.

LPA toured 10 resident rooms. Toured rooms in assisted living units were rooms 102, 109, 110, 125, 135 on the first floor and rooms 205, 214, 225, 228, and 232 on 2nd floor.

LPA interviewed 6 residents.

LPA will return at a later date to complete the annual visit.

Exit interview completed, copy of report printed for Administrator.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2023
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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