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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405809547
Report Date: 06/30/2025
Date Signed: 06/30/2025 03:27:44 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
06/28/2024 and conducted by Evaluator Melisa Rankin
COMPLAINT CONTROL NUMBER: 29-AS-20240628143308
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: 97DATE:
06/30/2025
UNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Ronald FreemanTIME COMPLETED:
02:35 PM
ALLEGATION(S):
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Facility did not seek timely medical care for resident
Facility did not meets resident's needs
Facility did not provide adequate supervision
Facility did not observe change of condition in resident
Facility did not conduct reappraisal of resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rankin conducted a subsequent complaint visit to issue final findings on this investigation. LPA met with Ronald Freeman and explained the purpose of the visit. During the investigation, LPA conducted an initial visit on 7/2/2024 from 2:14pm to 4:30pm where LPA conducted interview with administrator and obtained relevant documents. LPA conducted a visit on 5/29/25 from 12:11pm to 3:17pm, where LPA again interviewed administrator, and re-reviewed records. Additional staff interviews were conducted via phone on 5/30/25 at 1:09 to 1:52 p.m., in person on 6/23/25 at approximately 12:52pm to 1:10pm, and via phone on 6/26/25 at 10:24am to 10:32am and 12:19pm to 12:39pm. LPA attempted to call/interview nine staff listed on the staff roster who were staff in the memory care unit during the timeframe Resident 1 (R1) resided in the facility. Four of those staff were interviewed and the remaining five staff were contacted, but did not respond to requests for interview. Interviews on 6/25/25, 6/27/25 and 6/30/25 were conducted with witnesses. Additional documentation was reviewed and collected on 6/30/25. LPA also reviewed medical records for R1. During interviews with the facility regarding the last entry in the narrative charting dated 12/9/22, staff and administrator stated that a new electronic charting began around this time, this new electronic charting has since been changed to another system and the original electronic charting notes are unavailable due to no access to the prior system, per administrator.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2025
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 8
Control Number 29-AS-20240628143308
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: 06/30/2025
NARRATIVE
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Prior to admission into the facility, R1 had two hospital visits for concerns of head trauma. Hospital records for R1 indicated on 6/30/2022, a CT scan was completed due to concerns of head trauma, which was negative.
R1 was admitted to the hospital on 10/8/2022 and discharged 10/16/2022. R1’s CT scan and hospital records indicate “either ex vacuo subdural prominence or chronic thin bilateral subdural hematomas” and “no acute bleed.” The records indicate R1 will continue their Eliquis medication because there is a “low risk of bleed despite having a single fall.” Records also noted the hospital staff “discussed this with [R1’s family] that with [R1’s] history of multiple falls they should consider taking [R1] off Eliquis or discuss this with [R1’s] cardiologist.”

R1 moved into the facility in November 2022. R1’s physician’s report dated 11/7/2022 states R1’s primary diagnosis was “status post fall, L5 fracture, C1 fracture” with secondary diagnoses of dementia, atrial fibrillation, chronic embolism, thrombosis, and hypertension. R1 continued to take Eliquis. The physician’s report indicates R1 was confused/disoriented, able to follow instructions and communicate needs, and needed assistance with bathing, dressing/grooming, and toileting but was incontinent at times.

R1’s initial health and service evaluation (assessment) dated 11/10/2022 states R1 was a fall risk and had 3 falls during the 25 days they were at the Skilled Nursing Facility (SNF). R1’s Morse Fall Scale assessment indicated they were a level 3 out of 3 fall risk, and it states, “implement high risk fall prevention interventions.” Facility document “CA Health and Service Evaluation” document has handwritten notes on page 1 that state that “Stand by on off toilet” and “Standby dress” is noted. Handwritten notes also indicate “falls” and “3 in Valley Oaks,” the resident is on “(blood thinners), and “Eliquis free through program.” The assessment indicates R1 had limited mobility, decreased balance and “gait limited,” and R1 would be provided with stand-by assistance for transfers, toileting, bathing, and dressing. There is no signature of who signed the document. The Morse Fall Scale and Evaluation forms note that facility was aware of a recent history of falls and resident was on blood thinners prior to intake.

On 11/22/2022 at 2:46am, the facility faxed a Physician Communication form to R1’s Primary Care Physician (PCP), indicating R1 had an unwitnessed fall and was found lying on their right side on the floor outside their bathroom. No complaints of pain and no apparent injuries. R1 was reminded to use their pull cord. On 11/23/2022 at 5:48pm, the facility faxed a Physician Communication form to R1’s Primary Care Physician (PCP), indicating R1 had a fall when care staff were dressing R1 after a shower. There were no signs of redness or bruising and no complaints of pain. On 11/26/2022 at 9:35am, the facility faxed a Physician Communication form to R1’s Primary Care Physician (PCP), indicating R1 had an unwitnessed fall with no complaints of pain and no signs of injury.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2025
LIC9099 (FAS) - (06/04)
Page: 8 of 8
Control Number 29-AS-20240628143308
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: 06/30/2025
NARRATIVE
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 On 12/9/2022 at 1:57pm, the facility faxed a Physician Communication form to R1’s Primary Care Physician (PCP), indicating R1 had an unwitnessed fall in their apartment with no complaints of pain and no signs of injury. On 1/31/2023 at 12:43pm, the facility faxed a Physician Communication form to R1’s Primary Care Physician (PCP), indicating R1 had an unwitnessed fall in their apartment, has small skin tear on right hand but no complaints on pain.

R1 had numerous visits by Occupational Therapy and Physical Therapy from November 2022 through March 2023, with the goal of getting stronger and preventing falls.

R1’s updated health and service evaluation results (assessment) dated 4/26/2023 indicates R1 would receive standby assistance for dressing, reminders and setup assistance for toileting, was continent but wore pull-ups/protective underwear, needed assistance with medication, no additional status checks, was a fall risk, was able to walk with walker, reminders to use their walker to go to meals, independent with transfers, standby assistance for bathing two times per week with a shower chair, provided reminders and setup assistance for grooming/personal hygiene, and uses chargeable hearing aids. The assessment indicates resident was oriented to person, has current history of occasional disorientation to person/place/time/situation, requires some direction and reminding from others, but is able to communicate effectively and make needs known. The assessment states R1 could not leave unassisted, will be provide with staff intervention assistance for wandering in public areas, not exit-seeking/intrusive behaviors, current or history of occasional poor judgement, may resist care at times, needs supervision because resident may make inappropriate decisions. The assessment also indicates R1 could use their emergency response system pull cord. The assessment was signed 4/27/2023 by R1’s responsible party, the resident services director, and the executive director.

Current administrator stated that a review of the 4/26/2023 assessment provided that resident was improving based on the service plan being reduced in score, which equates to a reduction in service charges to the resident.

On 5/9/2023 at 2:18am, the facility faxed a Physician Communication form to R1’s Primary Care Physician (PCP), indicating R1 was found in bed with a cut near their right eye and a tear on right hand. There was dried blood present, and R1 did not know what happened. First aid was provided. Administrator (who was not the administrator at the time of this complaint), noted based on the facility documents available, there was no indication how severe the cut or skin tear were. Administrator also indicated since R1 needed assistance with transfers, it seems unlikely they could have fallen out of bed and put themselves back in without staff assistance.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 29-AS-20240628143308
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: 06/30/2025
NARRATIVE
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On 7/5/2023 at 6:24pm, the facility faxed a Physician Communication form to R1’s Primary Care Physician (PCP), indicating R1 had a fall in the hallway with no walker, had no visible injury or complaint of pain, and the fall was witnessed by a visitor.

On 7/9/2023, R1 was taken by R1’s family to the hospital “for evaluation of jaw pain and swelling.” CT imaging was obtained to evaluate for a possible mandibular fracture, which was negative. CT scan and hospital records indicate R1 had “mixed attenuation right subdural hematoma consistent with an acute on chronic bleed” and “mild atrophy and mild chronic small vessel ischemic changes.” Hospital notes also indicate Eliquis would likely be discontinued due to recurrent falls, and “at least two episodes of subdural hematoma.” There is no indication exactly when the subdural hematoma(s) occurred. R1 was discharged from the hospital on 7/12/2023. An addendum created by the physician on 7/28/2023 noted among other things, antibiotics would be given for an odontogenic infection “fell two weeks ago and cracked a tooth in the same area.” Hospice consultation and records for 7/10/2023 indicate R1’s family member stated R1 had two brain bleeds in a two-week timespan. However, there were no medical records to support this exact statement.

R1 was admitted to hospice on 7/12/2023. Multiple hospice records indicated R1 was alert and oriented and could answer some questions. Hospice records from 7/14/2023 also indicated R1’s baseline is independent with most ADLs with stand-by assistance by caregiver, and R1 ambulated with a walker.

On the allegation: Facility did not seek timely medical care for resident.
It was alleged R1 had a fall in May 2023, which resulted in them losing a tooth. It was alleged R1 was found covered in blood in the morning, but no medical attention was sought. LPA reviewed documentation for R1. No documentation was found specifying resident had a “fall”, however, a Physician Communication document was faxed to R1’s Primary Care Physician (PCP) on 5/9/2023 at 2:18am. The form indicated “your patient sustained an injury last night. [R1] was in bed with a cut near [their] right eye and a tear on right hand.” “…there was dried blood present. [R1] was cleaned and bandaged. [R1] did not know what had happened.” First aid was provided. Physician responded with a signature and date of 5/09/23 per the fax stamp of 5/09/23 at what appears to be 10:38 am. There was only a signature, no instructions noted in the “Physicians Instructions” section. Hospital records from July 2023 refer to a “cracked tooth.” There is no facility documentation of an injury to R1’s tooth. R1’s family member could not provide documentation about the tooth either, but did provide a photo showing a gap in their teeth, indicating a missing tooth. All staff interviewed stated they did not remember R1 losing a tooth. All staff interviewed indicated they knew of the requirement to seek timely medical care for residents, and explained the facility’s protocols.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 29-AS-20240628143308
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: 06/30/2025
NARRATIVE
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It was also alleged per the reporting party that on 7/8/2023, R1’s jaw was swollen, and a family member took R1 to the Emergency Room (ER). Per the reporting party, the CT scan found “two brain bleeds” “about a month apart.” LPA reviewed a Physicians Communication faxed on 7/5/2023 at 6:24pm which had a return note from the doctor faxed back at what appears to be 7/6/2023 at approximately 09:01am. Physician notes which were signed and dated 7/6/23, state “If [they have] no pain or obvious injury continue to observe.” LPA also reviewed an incident report (IR) submitted by the facility on 7/27/2023 for an incident dated 7/9/2023. The IR states on 7/9/2023 at 4:30pm, R1’s family member called to report they had taken R1 to urgent care for an antibiotic prior to a dental appointment, during which time R1 experienced a change in condition including increased heart rate. The family member took R1 to the ER to be evaluated. The IR states R1 was admitted to the hospital but discharged back on 7/12/2023 with no new diagnosis on their discharge orders but was stated to be appropriate for hospice. R1’s family member confirmed they observed R1’s jaw swollen and that is why they took R1 to the ER. Medical records indicated R1 presented to the ER for evaluation of jaw pain and swelling. The records note R1 was in “no apparent distress,” and was confused at their baseline. Records note some tenderness and induration over the mandible at the midline, which appear to correspond to a broken tooth and gingival erythema with no discrete abscess. Staff interviewed who remembered R1, stated they did not recall R1 having a change in condition on 7/6/2023, except for what the family member reported. All staff interviewed indicated they knew of the requirement to seek timely medical care for residents, and explained the facility’s protocols. Interviews and record review did not reveal any change in condition for R1 during this time that would have required medical attention. Based on the information obtained, the allegation may have happened or is valid, but there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated at this time.

On the allegation: Facility did not meet resident's needs. It was alleged the facility did not meet R1’s needs due to the multiple falls sustained. R1 entered the facility as a known fall risk in November 2022 and sustained multiple falls. R1 also received Occupational and Physical Therapy as a fall intervention from November 2022 to March 2023, and R1’s falls decreased overall since admission. R1 did not require additional supervision, such as a 1 on 1 caregiver, and required less care based on their reappraisal in April 2023. The investigation did not reveal any indications that R1’s care needs were not met. There was no additional charting notes or documentation that supported the facility did not meet R1’s needs. Based on the information obtained, the allegation may have happened or is valid, but there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated at this time.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 29-AS-20240628143308
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: 06/30/2025
NARRATIVE
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On the allegation: Facility did not provide adequate supervision. It was alleged that due to a lack of staffing, R1 was provided inadequate supervision. LPA interviewed staff who stated that to their remembrance, the year of 2022 and 2023 the staffing was 2 caregivers consistently on each shift, in addition to a medical technician. One staff who worked NOC stated they remember being fully staffed, with the exception of some weekends and that there would be 2 caregivers on the Memory Care side during their shifts. Another staff interviewed started in approximately August of 2023 and stated that while they were there, the facility was fully staffed, or staff would cover shifts as needed. R1 needed stand-by assistance with some activities of daily living, but did not require constant supervision or a 1:1 staff per their service plan. As noted, R1’s service plan score reduced in April of 2023 as they required less services. Additionally, multiple hospice records from July 2023 indicate R1 was alert and oriented and could answer some questions. Staff schedules from the timeframe of the complaint were unavailable, due to the length of time since the incidents occurred. Based on the information obtained, the allegation may have happened or is valid, but there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated at this time.

On the allegation: Facility did not observe change of condition in resident. It was alleged in May 2023, a family member saw R1 and noticed R1 was missing a tooth; however, R1’s responsible party was not informed about this. Interview with R1’s family member revealed that during the visit on 5/9/23, they noticed a front tooth was missing, and R1 still had blood on their face. The family stated they asked caregivers about R1 and what had happened. Per the family member, the caregivers seemed to acknowledge an incident happened during the night and cleaned R1 up, but did not indicate R1 was missing a tooth. LPA requested documentation supporting the allegations and family was unable to provide. The documentation provided by the facility did not indicate R1 had a fall or was missing a tooth. A Physician Communication form faxed to R1’s PCP on 5/9/2023 at 2:18am indicated R1 had a cut near their right eye, a tear on the right hand, and there was dried blood present. First aid was provided. No additional instructions were provided by the physician. During interview with family, photos were provided to LPA showing in December of 2022, R1 had all bottom teeth and in photo taken in 2023, there is a missing tooth in the bottom right side of R1’s mouth. Staff interviewed stated they did not remember R1 losing a tooth, and there was no documentation related to a lost tooth. Therefore, there is insufficient evidence to show that R1 was not observed for a change in condition.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 29-AS-20240628143308
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: 06/30/2025
NARRATIVE
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It was also alleged per the reporting party that on 7/8/2023, R1’s jaw was swollen, and a family member took R1 to the Emergency Room (ER). Per the reporting party, the CT scan found “two brain bleeds” “about a month apart.” Physician’s Communication forms faxed on 7/5/2023 at 6:24pm were sent informing R1’s PCP of a fall. The form was faxed back on 7/6/2023 at 09:01am and stated if R1 had no pain or obvious injury, continue to observe. LPA also reviewed an incident report (IR) submitted by the facility on 7/27/2023 for an incident dated 7/9/2023. The IR states on 7/9/2023 at 4:30pm, R1’s family member called to report they had taken R1 to urgent care for an antibiotic prior to a dental appointment, during which time R1 experienced a change in condition including increased heart rate. The family member took R1 to the ER to be evaluated. The IR states R1 was admitted to the hospital but discharged back on 7/12/2023 with no new diagnosis on their discharge orders but was stated to be appropriate for hospice. Interviews and record review did not reveal any change in condition for R1 during this time.

Interview with family members contradicts that the resident was taken to urgent care or had a dental appointment on 7/9/2023. The family stated R1 was directly taken to the ER due to the time of day that they observed the swelling. Family members stated that the purpose of the ER visit was to get antibiotics due to the swelling in R1’s jaw, and that during the assessment at the ER the resident did have a change in condition with R1’s heart rate, which further prompted the discussion of a fall occurring a few days prior and led to the CT Scan being done. Family stated that R1 could not go to the dentist due to the stress and confusion it causes R1. Based on the information obtained, the allegation may have happened or is valid, but there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated at this time.

On the allegation: Facility did not conduct reappraisal of resident. It was alleged the facility did not conduct reappraisal of R1 upon change of condition. R1 was admitted to the facility in November 2022 and was initially assessed on 11/10/2022. It was alleged R1 sustained five falls at the facility between November 2022 and March of 2023, which was supported by documentation. R1 did receive physical therapy and occupational therapy from 11/17/2022 to 3/17/2023. On 4/26/2023 an updated assessment was completed in which R1’s care level was lowered based on the facility’s reassessment of resident. An additional incident was alleged, and documentation supports, that on 5/9/2023 R1 was found in bed with a cut near the right eye, a tear on the right hand, and dried blood present. R1’s physician was notified, and no additional medical attention was deemed necessary.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 29-AS-20240628143308
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: 06/30/2025
NARRATIVE
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The family alleges that a tooth was missing following this incident, but the investigation did not reveal any documentation to support this claim. While an additional incident occurred following the re-appraisal on 4/26/23, the resident records provided by the facility, the reporting party, and by the family do not show a “significant change in condition” that would necessarily require a reappraisal. Based on the information obtained, the allegation may have happened or is valid, but there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated at this time.

Exit interview conducted. Copy of report issued at the time of the visit.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 8