405809547-10-22-2024-29-AS-KBUY-DAJNPJ-20241030103825

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405809547
Report Date: 10/22/2024
Date Signed: 10/22/2024 04:59:37 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
04/03/2024 and conducted by Evaluator Erika Miller

COMPLAINT CONTROL NUMBER: 29-AS-20240403105525

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: 103	DATE:	10/22/2024
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Ronald Freeman		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff handled resident in a rough manner

Staff did not assist with medication as prescribed

Staff did not address a resident's change in medical condition

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Erika Miller (Miller) conducted an unannounced complaint visit and issued final findings on the allegations above. During the investigation, LPA Miller, toured the facility and interviewed staff, and residents on October 22, 2024. LPA reviewed relevant documents. LPA met with Ronald Freeman, administrator and explained the purpose of the visit.

On the allegation: Staff handled resident in a rough manner
Reporting party (RP) alleges that they observed Resident 1 (R1), to be in severe pain and directed staff to stop their actions, (i.e.), stop changing R1’s brief.

Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Erika Miller
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024

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-20240403105525

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: 10/22/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

This is an amended report. Freeman disputes that staff handled resident in a rough manner. Freeman stated that staff is required to reposition Resident 1 (R1) to prevent bed sores and also when changing soiled briefs. R1 groans each time they are repositioned, and it is not unusual. Freeman stated that a witness (W1) was not aware that R1 groaned each time they were turned. Multiple care staff were provided to R1 to mitigate any discomfort and support R1’s body while being repositioned. A credible witness (CW1) advised Freeman that Staff 1 (S1) and W1 had a verbal dispute regarding turning the resident on 2/21/24 at approximately 12:30 p.m. S1 disregarded W1’s direction to stop and Staff continued to change R1’s brief. CW1 subsequently advised that W1 will not return and to date, has not returned to facility.

S1 refutes that they handled R1 in a rough manner. S1 further stated that R1 was not screaming, but moaning as R1 normally did when repositioned. S1 advised LPA that this was W1’s first encounter with R1. S1 alleges W1 became agitated at hearing R1’s moaning and was concerned for R1. W1 called their supervisor, who instructed staff to stop. S1 advised W1 that R1 could not be left in a soiled brief and left unclothed. Staff ultimately changed brief and put R1 back in bed.

Krystal Cornejo (Cornejo), Resident Services Director, stated that she never observed any staff handle R1 in a rough manner, nor did she receive any complaints of staff handling R1 in a rough manner. Cornejo was not present on the date of the incident that occurred on 2/21/24, however, Cornejo is familiar with R1 and is aware that it was not unusual for R1 to make grunting and moaning noises. Cornejo stated that R1 could state when their body was hurting and staff did not report that R1 was screaming on the date of incident.

Multiple staff stated that they never observed anyone handle resident in rough manner, nor did any residents complain about being handled in a rough manner.

7 of 7 residents stated that they are treated with dignity and respect by staff. 7 of 7 residents stated that staff do not handle them in a rough manner.

Based on multiple interviews, there is not sufficient evidence to support this allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. (Continued on 9099-C)

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Erika Miller
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 29-AS-20240403105525

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: 10/22/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

On the allegation: Staff did not assist with medication as prescribed

Reporting party (RP) alleges that Staff 1 (S1) advised that R1 had not received medication for approximately 20 hours nor was R1 pre-medicated before changing brief.

Freeman disputes that staff did not assist with medication as prescribed, but will defer to Krystal Cornejo (Cornejo), Resident Services Director. Cornejo stated that R1 was on routine pain medication and was administered as prescribed.

S1 refutes that they advised Hospice nurse that R1 went without pain medication for 20 hours. S1 stated that pain medication was administered 30 minutes prior to changing R1.

LPA reviewed the MAR that reflects that R1 was provided pain management from 2/1/24 through 2/21/24, including an AM dose of Lorazepam on 2/21/24 and Methadone from 2/14/24 to 2/21/24.

There is no evidence to support that staff did not administer medication as prescribed.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

On the allegation: Staff did not address a resident's change in medical condition

Freeman stated that R1 was a resident prior to being on hospice. As R1’s condition declined there was a change in services and staff kept up with R1’s change of condition.

Krystal Cornejo (Cornejo), Resident Services Director, advised that Resident 1 (R1) was admitted to facility 8/2/2021 and had issues with mobility, but was independent and managed her own meds prior hospice. R1 crashed a motorized scooter into wall, went to hospital, and had a change in condition. Shortly thereafter, R1 was admitted to hospice on 11/14/2023. (Continued on 9099-C)

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Erika Miller
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 29-AS-20240403105525

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: 10/22/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Facility provided documentation to support that R1’s change of medical conditions was addressed in the 1/23/24 Service Plan and Hospice Care Plan. Cornejo advised that facility ensured that R1 was routinely monitored, every two hours. R1’s family assisted, and staff was called as needed. R1 was a 2-person assist, but because of mobility issues, facility had additional staff present to transfer appropriately.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Exit interview conducted, copy of report issued.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Erika Miller
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 4