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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405809547
Report Date: 02/08/2024
Date Signed: 02/08/2024 05:57:18 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
02/06/2024 and conducted by Evaluator Erika Miller
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20240206161459
FACILITY NAME:OAKS AT NIPOMO, THEFACILITY NUMBER:
405809547
ADMINISTRATOR:RONALD C. FREEMANFACILITY TYPE:
740
ADDRESS:177 MARY AVENUETELEPHONE:
(805) 723-5206
CITY:NIPOMOSTATE: CAZIP CODE:
93444
CAPACITY:122CENSUS: DATE:
02/08/2024
UNANNOUNCEDTIME BEGAN:
12:52 PM
MET WITH:Ronalad Freeman, Administrator TIME COMPLETED:
06:10 PM
ALLEGATION(S):
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Staff did not discard contaminated food.
INVESTIGATION FINDINGS:
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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 Memory Care Unit and interviewed staff, and residents on February 8, 2024, from 1:39 p.m. to 3:15 p.m. LPA also obtained and reviewed relevant documents. LPA met with Ronald Freeman, administrator and explained the purpose of the visit.

On the allegation: Staff did not discard Contaminated food.
On February 5, 2024, a witness visited the facility, and observed open containers of food in the small fridge in the pantry area, including a container with mold growing on it. See photograph of moldy juice box. The memory care director stated that staff is instructed to check the refrigerator on a daily basis. In addition, the NOC shift in memory care is required to go through the refrigerator and check for expired foods once a week as outlined in the NOC Caregiver Duties check list. In the event, food is expired, the director or staff will communicate with the kitchen chef, to bring items that are needs.



Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika MillerTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024
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 7
Control Number 29-AS-20240206161459
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: 02/08/2024
NARRATIVE
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Three of three Staff members stated that the main kitchen brings a cart with hot food. The prepared food is kept in a steam table and then plated for residents. At the end of each meal, leftover plates are wrapped and labeled with the time, date and name of resident. Staff stated that lunch plates can be left out on the counter for up to one hour, then placed in the refrigerator and then tossed in trash by 2:00 p.m. Staff stated that expired foods are tossed out and Staff always reviews the expiration date before serving residents. Staff has never observed moldy food in refrigerator, including moldy juice boxes. Staff 1 stated that the Director of Kitchen, ensures that food supplies like hot chocolate and cereal are well stocked and checks for expired foods.

Staff serves dinner at 5:00 p.m. Staff stated that wrapped plates can sit on a counter until 7:00 p.m. but is thrown away and not served to residents. Staff observed expired food in the refrigerator about a year ago. Staff further stated that resident family members often bring food and place in the refrigerator with their name and room number. Staff is not aware of anyone from main kitchen checking the refrigerator for expired foods. However, main kitchen staff stocks the refrigerator and cleans the kitchen.

Staff stated that in the event a resident does not eat dinner, the plate is wrapped, labeled and may remain on the counter top unrefrigerated as late as 10:30 p.m. Staff stated that this occurs three times a week. Staff has offered these plates to night shift staff and if they are not eaten by staff, they dispose of food in trash. Kitchen Staff typically stock and dispose of expired foods. Staff stated that there have been occasions when juice has been expired and he has had to dispose of item. In one instance there was an opened bottle of juice that had been sitting for more than a month. Staff reminds staff to be vigilant and notifies a supervisor that he has disposed of the item. Staff is not aware of a scheduled date to go through the refrigerator and check for expired foods.

Based on the information obtained, the allegation is deemed Substantiated at this time.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika MillerTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 7
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
02/06/2024 and conducted by Evaluator Erika Miller
COMPLAINT CONTROL NUMBER: 29-AS-20240206161459

FACILITY NAME:OAKS AT NIPOMO, THEFACILITY NUMBER:
405809547
ADMINISTRATOR:RONALD C. FREEMANFACILITY TYPE:
740
ADDRESS:177 MARY AVENUETELEPHONE:
(805) 723-5206
CITY:NIPOMOSTATE: CAZIP CODE:
93444
CAPACITY:122CENSUS: DATE:
02/08/2024
UNANNOUNCEDTIME BEGAN:
12:52 PM
MET WITH:Ronalad Freeman, Administrator TIME COMPLETED:
06:10 PM
ALLEGATION(S):
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 Staff did not keep kitchen clean or free from rodents.



INVESTIGATION FINDINGS:
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On the allegation: Staff did not keep kitchen clean or free from rodents.
On February 5, 2024, a witness observed a dirty silverware catcher that had food and or other waste on the three rotors. Witness also observed a glue trap for mice in an unsecured cabinet in the kitchenette area, which was accessible to residents in care.

The memory care director, advised that there are no glue rodent traps in the memory care. The trap under the sink is a critter trap to keep ants out of kitchen area and there is no poison in the trap.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika MillerTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 29-AS-20240206161459
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: 02/08/2024
NARRATIVE
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The door under the sink is typically locked but the locking mechanism is lose and onsite maintenance will repair it February 9, 2024. Nothing under the sink is a danger to residents, but glass vases will be moved to a locked storage closet. The memory care director further advised that resident was hoarding forks and spoons, as such, the kitchen implemented a magnetic silverware catcher. The equipment was washed weekly and effective February 7, 2024, the equipment is washed daily.

Three of three staff has no knowledge of a trap under sink and has no knowledge of any rodent issues. There was an issue with ants during the recent rainstorms and pest control came in last week to resolve it. Staff stated that small frogs and crickets enter the building from under the exit door and dining room door, during rainstorms. Staff stated that the magnetic silverware catcher was procured within the last four months and is cleaned weekly. Staff stated it will be cleaned more often. The cabinet under the kitchen sink has not been locked because chemicals are no longer kept in that location. Staff stated that they cleaned the magnetic silverware catcher on one occasion and has advised staff to clean it. Staff stated that the equipment is cleaned daily but it is very hard to get very clean. Staff stated that the magnetic silverware catcher is always dirty and is not sure how often it is cleaned.

Based on the information obtained, the allegation is deemed Unsubstantiated at this time.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika MillerTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 29-AS-20240206161459
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/12/2024
Section Cited
CCR
87555(b)(23)
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All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures. This requirement was not met as evidence by
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Administrator agrees to issue a written memo to all staff who oversee the food areas of the facility, explaining expectations regarding the food and food safety. Administrator will provide a list of signatures of staff acknowledging the memo.
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Based on interview and observation, the licensee did not comply with the section cited above when Staff failed to properly store food in refrigerator and was left out for several hours, which posed a health 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: Erika MillerTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7