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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405809547
Report Date: 08/27/2024
Date Signed: 08/27/2024 12:08:44 PM

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
01/19/2023 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20230119132542
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: 106DATE:
08/27/2024
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Ron FreemanTIME COMPLETED:
12:15 PM
ALLEGATION(S):
1
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8
9
Facility staff handles residents in a rough manner resulting in skin tears.
Facility staff using profanity towards residents.
Facility staff does not wear gloves when preparing food.

INVESTIGATION FINDINGS:
1
2
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4
5
6
7
8
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10
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13
Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above to deliver final findings in the complaint investigation. LPA met with Ronald Freeman Administrator and explained the purpose of the visit.

LPA De Leon conducted the initial investigation on 01/20/2023, LPA toured the kitchen with Administrator, LPA collected the following records: Resident Roster with telephone numbers, Staff Roster with Telephone numbers, Staff schedule for January 2023 for Kitchen staff, caregivers and med-tech's, Kitchen menu, Kitchen cleaning checklist, Any disciplinary records for staff 1 (S1) or any other staff using profanity, any incident reports of Residents with food poisoning, Any resident evictions for January 2023, and Infection Control Training Records for all staff, LPA interviewed staff at 1:19pm, 2:02pm, 2:20pm, 2:45pm, and 3:20pm.

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: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
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-20230119132542
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: 08/27/2024
NARRATIVE
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LPA De Leon conducted a subsequent visit to the facility on 08/23/2023. LPA collected additional records: staff schedules, resident roster and staff schedules for August 2023, Staff disciplinary records for 2023,
and Call pendant logs. LPA conducted interviews with staff at 10:15am, 11:10am, 11:50am, 12:05pm, 1:05pm, 1:20pm, 1:40pm, 2:20pm, 3:30pm, and 4:15pm. LPA interviewed residents at 12:15pm, 12:30pm, 12:45pm, and 2:55pm.
LPA De Leon conducted additional staff interviews on 08/24/2023 at 11:18am and resident interviews at 12:20pm, 12:40pm, 1:45pm, 2:12pm, 3:15pm, 5:00pm, and 5:05pm.
On the allegation: Facility staff handles residents in a rough manner resulting in skin tears. LPA interviewed staff which revealed 3 staff felt S1 handled residents in a rough manner and several residents told staff that they did not want assistance from S1. LPA reviewed disciplinary records for S1 which revealed S1 had a corrective counseling documentation dated 01/10/2023 where a peer reported S1’s approach with residents was a concern, S1 could be intimidating in size and tone of voice. The facility had a documented discussion with S1 for prohibited conduct -Caring for resident in an unprofessional manner and speaking to a resident in an unprofessional or discourteous manner, S1 was re-trained in customer service, dementia care, and proper re-directing techniques. On 02/21/2023 an internal investigation was conducted by the facility from 02/21/2023-02/24/2023 for allegation of elder abuse by S1. S1 was put on leave 02/21/2023 and was terminated based on the investigation and interviews from residents and staff for a violation of policy- prohibited conduct as of 2:45pm on 02/24/2023. Based on the evidence this allegation is deemed Substantiated at this time.

On the allegation: Facility staff using profanity towards residents. LPA reviewed records for S1 due to an internal investigation on 02/21/2023 conducted by the facility from 02/21/2023-02/24/2023 for allegation of elder abuse by S1. S1 admitted to using profanity when discussing a resident or care related conversations with other staff. Staff interview revealed staff heard S1 use profanity in front of residents. Based on the evidence this allegation is Substantiated.

On the allegation: Facility staff does not wear gloves when preparing food. LPA De Leon interviewed staff which revealed staff 2 (S2) does not wear gloves when preparing food in the kitchen. Disciplinary records were reviewed on S2, S2 no longer works at the facility, and S2 was let go for other reasons. Based on the evidence this allegation is Substantiated.

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

DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20230119132542
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: 08/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/29/2024
Section Cited
CCR
87468.2(a)(8)
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(a)... (8)To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse.This requirement was not met as evidenced by:
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Administrator agreed to hold a training on all Personal Rights and Mandated Reporting and Abuse for all staff, provide proof of training with staff signatures and an up-to-date LIC 500.
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Based on interviews and record review the Licensee did not comply with the regulation above, S1 handled residents roughly and was terminated from employment due to abuse complaints which poses an immediate health and safety risk to residents in care.
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Type B
08/27/2024
Section Cited
CCR
87468.1(a)
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(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1)To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by:
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Administrator agreed to re-train all staff on the facility’s policy and procedures for resident care. Provide proof of training with staff signatures and an up-to-date LIC 500.
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14
Based on interviews and record review the Licensee did not comply with the regulation above S1 used profanity talking about the residents with other staff and using profanity in the presence of the residents which poses a potential personal rights risk to residents in care.
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9
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14
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: 08/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 29-AS-20230119132542
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: 08/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/03/2024
Section Cited
CCR
87555(b)(15)
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(b)The following food service requirements shall apply:(15)All persons engaged in food preparation and service shall observe personal hygiene and food services sanitation practices which protect the food from contamination. This requirement was not met as evidenced by:
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Administrator agreed to train all kitchen staff in AL/MC regulation 87555 Food Service, facility policy and procedures for food handling, preparing, cooking, and serving. Provide Proof of Training and an up-to-date LIC 500 to CCL.
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Based on interviews the Licensee did not comply with the above regulation, staff preparing food did not wear gloves which poses a potential health and safety risk to residents in care.
8
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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: 08/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
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
01/19/2023 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20230119132542

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: 106DATE:
08/27/2024
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Ron FreemanTIME COMPLETED:
12:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff did not properly store food causing residents to have food poisoning.
Facility staff threatened to evict resident.
Facility kitchen is dirty.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above to deliver final findings in the complaint investigation. LPA met with Ronald Freeman Administrator and explained the purpose of the visit.

LPA De Leon conducted the initial investigation on 01/20/2023, LPA toured the kitchen with Administrator, LPA collected the following records: Resident Roster with telephone numbers, Staff Roster with Telephone numbers, Staff schedule for January 2023 for Kitchen staff, caregivers and med-tech's, Kitchen menu, Kitchen cleaning checklist, Any disciplinary records for staff 1 (S1) or any other staff using profanity, any incident reports of Residents with food poisoning, Any resident evictions for January 2023, and Infection Control Training Records for all staff, LPA interviewed staff at 1:19pm, 2:02pm, 2:20pm, 2:45pm, and 3:20pm.

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: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
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-20230119132542
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: 08/27/2024
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
LPA De Leon conducted a subsequent visit to the facility on 08/23/2023. LPA collected additional records: staff schedules, resident roster and staff schedules for August 2023, Staff disciplinary records for 2023,
and Call pendant logs. LPA conducted interviews with staff at 10:15am, 11:10am, 11:50am, 12:05pm, 1:05pm, 1:20pm, 1:40pm, 2:20pm, 3:30pm, and 4:15pm. LPA interviewed residents at 12:15pm, 12:30pm, 12:45pm, and 2:55pm. LPA De Leon conducted additional staff interviews on 08/24/2023 at 11:18am and resident interviews at 12:20pm, 12:40pm, 1:45pm, 2:12pm, 3:15pm, 5:00pm, and 5:05pm.

On the allegation: Facility staff did not properly store food causing residents to have food poisoning. LPA conducted interviews with staff and residents which revealed some residents got sick from a meal served by the facility in 01/2023. The interviews conducted do no mention anything about food storage or food poisoning. The facility did not have any incident reports of food poisoning and none of the residents went to the ER for any type of food poisoning. LPA conducted unannounced visits on 01/20/2023 and toured the kitchen, all food was stored properly. LPA found no evidence to support food poisoning or improper storage of food by facility staff. Due to the lack of evidence to support this allegation it is deemed Unsubstantiated.

On the allegation: Facility staff threatened to evict resident. LPA interviewed staff and residents which revealed no residents were threatened with eviction. According to staff interview a resident said a physical therapist not an employee of the facility told a resident that they needed to do the required physical therapy or could risk eviction if the resident didn’t do the rehab. Another staff said the physical therapist is stern to the clients about rehab and some residents do not like to hear it. Based on the evidence this was not a facility staff therefore the allegation is deemed Unsubstantiated at this time.

On the allegation: Facility kitchen is dirty. LPA De Leon conducted an unannounced visit on 01/20/2023, toured the facility Commercial kitchen and did not find it to be dirty. LPA conducted interviews with 15/16 staff which revealed staff did not think the kitchen was dirty. Resident interviews revealed 11/11 had not seen the inside of the kitchen, but a resident reported that other residents had and those residents were impressed with the kitchen, so the resident would not think it would dirty, if other residents were impressed. LPA reviewed schedules for kitchen staff with job duties which revealed the kitchen could be short staffed at times. It was stated in interviews that when short staffed if something did not get done on a staffs shift, it was done by staff on the next shift. Due to the lack of evidence this allegation is deemed Unsubstantiated ay this time.
Exit interview conducted and copy of report printed for Administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6