<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405809547
Report Date: 07/11/2024
Date Signed: 07/11/2024 02:09:48 PM


Document Has Been Signed on 07/11/2024 02:09 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
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, THEFACILITY NUMBER:
405809547
ADMINISTRATOR:RONALD C. FREEMANFACILITY TYPE:
740
ADDRESS:177 MARY AVENUETELEPHONE:
(805) 723-5206
CITY:NIPOMOSTATE: CAZIP CODE:
93444
CAPACITY:122CENSUS: DATE:
07/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Sheryl McCaskill, Operational SpecialistTIME COMPLETED:
02:15 PM
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
Licensing Program Analyst (LPA) Rankin conducted an unannounced visit to the facility to conduct the facility annual inspection. LPA met with Sheryl McCaskill, Operation Specialist, and explained the purpose of the visit.
The following was inspected and noted during the annual visit:

Staffing: The facility employes 67 staff and 1 Administrators. Staff records are kept confidential. LPA reviewed 10 staff files and found all staff personnel documents to be complete.

Personnel Records & Training: The facility keeps confidential files for each staff member. A review of training records was started and will be concluded during the follow-up annual visit. Administrator Certificate expire on 08/26/2025.

Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Three out of ten (10) files were reviewed for signed Admission Agreements, Medical Assessments LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS), TB results, Personal Rights, and Safeguard for personal property and valuables. The final review of records will be done at a later date. The Facility does not handle cash resources for any of the residents in care. Facility does submit incident reports to the department when required.

Disaster Preparedness: The current emergency disaster forms were reviewed. The facility conducts quarterly disaster drills, last one was done on 6/25/24.

Tour and additional required annual reviews will be conducted at a later date.
Exit interview, report read and report provided.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa RankinTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1