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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405809547
Report Date: 06/19/2024
Date Signed: 06/19/2024 10:01:48 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
12/05/2022 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20221205120051
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: 104DATE:
06/19/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Raquel Cousins, Memory Care Director TIME COMPLETED:
10:15 AM
ALLEGATION(S):
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9
Staff do not assist residents with showering.
Staff do not answer residents' pendants in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above to deliver final findings of the complaint investigation. LPA met Raquel Counsins, Memory Care Director with and explained the purpose of the visit.

LPA De Leon conducted the initial 10-day visit on 12/13/2022 at 9:30am, LPA conducted staff interviews at 10:30am, 12:30pm, 1:10pm, 2:30pm, and collected records requested. On 08/23/2023 LPA De Leon conducted a subsequent visit to the facility interviewed staff at 10:15am, 11:10am, 11:50am, 12:05pm, 1:05pm, 1:20pm, 1:40pm, 2:20pm, 3:30pm, 4:15pm and interviewed residents at 12:15pm, 12:30pm, 12:45pm, 2:55pm, On 08/24/2023 collected records, conducted interviews with staff 11:18am, with residents at 12:20pm, 12:40pm, 1:45pm, 2:12pm, 3:15pm, 5:00pm and 5:37pm.

Continued 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
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 6
Control Number 29-AS-20221205120051
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 06/19/2024
NARRATIVE
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On the allegation: Staff do not assist residents with showering. LPA conducted interviews with 15 random staff and 12 random residents. Resident interviews revealed 5 out of 12 residents has issues with showers being rescheduled due to a lack of staffing available on their scheduled shower date and time. Staff interviews revealed 8 out of 15 staff said when the facility works short staffed with 2 caregivers or less showers run late, get rescheduled or when staff is available residents no longer want to take the shower.
R1 has had 25 missed showers due to one of the shower days being Sunday on the PM shift and staff was not available to help assist R1 with showers. R1 pays for a care plan with two shower days per month with assistance. R1 had brought up the missed showers with the Nurse and the Administrator at that time and they had agreed to give coupons for guest dining to make up for the missed showers. R1 wanted dollar for dollar in coupons for the missed showers. R1 stated as of 08/24/2023 R1 had not been reimbursed for the missed showers as the facility had decided they were not going to give coupons for guest meals to reimburse R1 for the 25 missed showers on the dollar-for-dollar bases. R1 was still waiting for the facility to decide how to refund R1 for the missed showers.

Staff interviews revealed that when the facility has 3 caregivers on the floor all the showers can be completed but when it goes down to 2 caregivers on the floor it gets harder to complete all the daily tasks and when 1 caregiver is on the floor alone several daily tasks can not get completed.

Based on the evidence this allegation is Substantiated at this time.

On the allegation: Staff do not answer residents' pendants in a timely manner. LPA interviewed with 8 out of 15 staff which revealed that if the facility is fully staffed, they can answer the residents’ pendants in 10 minutes or less. Staff had recently reported staff meetings where the pendants calls were reviewed with expectation on staff answering calls in 5-10 minutes. Staff stated if they have 3 caregivers on the floor they are able to meet all residents needs timely but when the facility has call offs and they become short staffed with 2 caregivers, they can work extra hard and still able to get most of the assigned duties completed, it is when the facility is short staffed with 1 care giver on the floor staff stated it is impossible to get all assigned tasks completed in a timely manner.

LPA conducted interviews with 5 out of 12 residents which revealed when pushing the pendant, it took longer than 10 plus minutes to get staff assistance, at times staff took 30 plus minutes to assist, or staff did not come at all. Continued 9099-C
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20221205120051
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 06/19/2024
NARRATIVE
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LPA reviewed another 11 randomly chosen residents from the facilities resident roster to review call pendants logs from 12/01/2022-12/13/2022. The logs revealed 8 out of the 11 residents had pendants calls with waiting times of over 11-30 minutes long.

Residents Pendant Logs revealed:
One resident had 12 calls during this time period of 12/01/2022-12/12/2022 that were in excess of 10 plus minutes 11 min, 12 min, 2-13min, 14min, 16 min, 17 min, 21 min, 27 min, 3-30 minutes.
Another resident had 11 calls during the same time period ranging from 11 minutes to 30 minutes.
Another resident had 5 calls during this same time period ranging from 11 minutes to 30 minutes.
Another resident had 13 calls during this same time period ranging from 15 minutes to 30 minutes.
A shared apartment had 2 calls over 19 and 20 minutes during the same time period.
Another resident shows 3 calls ranging in 11-30 minutes.
Another resident reviewed had 29 calls ranging from 11 minutes to 30 minutes.
The remaining 3 residents did not have any calls over 10 minutes.

Based on the evidence this allegation is Substantiated at this time.

Exit interview conducted, deficiencies cited, copy of report and appeal rights printed for Staff and emailed copy to Administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 29-AS-20221205120051
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/26/2024
Section Cited
CCR
87464(f)(1)
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(f)Basic services shall at a minimum include:(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by:
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Administrator agreed to staff according to resident’s census and needs of the residents, provide staffing schedules, LIC 500, Resident Roster, all Care and Med-tech staff take a training course on grooming and hygiene, shower schedules,
Continued below:
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Based on interviews and record review the Licensee did not comply with the regulation above several residents did not get showers according to the shower schedule which poses a potential health and safety risk to residents in care.
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and refusal process and provide proof of training with staff signatures to CCL. Provide refund to R1 for 25 missed showers and provide proof of refund to CCL.
Type B
06/26/2024
Section Cited
CCR
87468.2(a)(4)
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(a)...shall have all of the following personal rights:(4)To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by:
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Administrator agreed to provide training on Personal Rights 87468, 87468.1, 87468.2 and mandated reporting provide proof of training with staff signatures to CCL.
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Based on interviews and record review the Licensee did not comply with the regulation 8 out of 11 residents waited over 11-30 minutes to get assistance from staff which posses 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: 06/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
12/05/2022 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20221205120051

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: 104DATE:
06/19/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Raquel Counsins, Memory Care DirectorTIME COMPLETED:
10:15 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not meet residents' incontinence needs.
Staff do not properly supervise residents.
INVESTIGATION FINDINGS:
1
2
3
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5
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7
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Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above to deliver final findings of the complaint investigation. LPA met with Raquel Counsins, Memory Care Director and explained the purpose of the visit.

LPA De Leon conducted the initial 10-day visit on 12/13/2022 at 9:30am, LPA conducted staff interviews at 10:30am, 12: 30pm, 1:10pm, 2:30pm, and collected records requested. On 08/23/2023 LPA De Leon conducted a subsequent visit to the facility interviewed staff at 10:15am, 11:10am, 11:50am, 12:05pm, 1:05pm, 1:20pm, 1:40pm, 2:20pm, 3:30pm, 4:15pm and interviewed residents at 12:15pm, 12:30pm, 12:45pm, 2:55pm, On 08/24/2023 collected records, conducted interviews with staff 11:18am, with residents at 12:20pm, 12:40pm, 1:45pm, 2:12pm, 3:15pm, 5:00pm and 5:37pm.

Continued 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
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 6
Control Number 29-AS-20221205120051
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 06/19/2024
NARRATIVE
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On the allegation: Staff do not meet residents' incontinence needs. LPA interviewed staff and residents which revealed residents with incontinence care plans are conducted with rounds every 2 hours for staff to assist residents. Residents have call pendants and pull cords to use if assistance is needed at any other time. Call pendants are answered in order and according to needs of the residents. Some resident interviews stated some of the calls are not answered timely. Staff interviews revealed even when working short staffed on shift the incontinence needs of the residents are always taken care of on rounds, a few residents can be wet when checking on rounds, but all residents are checked and changed, residents are neglected, no residents have rashes or sores to indicate incontinence needs are not being met. Based on the lack of evidence this allegation is deemed Unsubstantiated at this time.

On the allegation: Staff do not properly supervise residents. The facility is an assisted living with a memory care unit on the premises serving senior residents that have added care plans based on the need of each resident. Assisted Living residents and Memory care residents have round -the -clock caregivers and medication technicians (Med-Tech) available by pendant or pull cords for assistance. The assisted living residents have the capability to call the front desk for non-urgent matters as well as call 911 for any urgent medical matters. The residents that have added supervision due to incontinence or memory care issues have 2-hour rounds conducted by the care giving staff to help. Some residents have added care plans for assistance with daily living for bathing, dressing, transfers, and 2-person assist. Residents interviewed did not have any concerns with supervision. Based on the lack of evidence this allegation is deemed Unsubstantiated at this time.


Exit interview conducted and copy of report printed for staff and emailed to Administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6