405809547-10-1-2025-29-AS-KBUY-DMYQMZ-20251031121824

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405809547
Report Date: 10/01/2025
Date Signed: 10/01/2025 04:50:30 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
09/24/2025 and conducted by Evaluator Melisa Rankin

COMPLAINT CONTROL NUMBER: 29-AS-20250924222649

FACILITY NAME:	OAKS AT NIPOMO, THE		FACILITY NUMBER:	405809547
ADMINISTRATOR:	RONALD C. FREEMAN		FACILITY TYPE:	740
ADDRESS:	177 MARY AVENUE		TELEPHONE:	(805) 723-5206
CITY:	NIPOMO	STATE: CA	ZIP CODE:	93444
CAPACITY:	122	CENSUS: 101	DATE:	10/01/2025
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Ronald Freeman		TIME COMPLETED:	04:50 PM

ALLEGATION(S):

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Facility doors are unsafe for residents in care.
Staff are not following residents admission agreements.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Melisa Rankin conducted an unannounced visit to initiate a complaint investigation regarding the above-mentioned allegations. LPA met with Ronald Freeman, to discuss the purpose of the visit and elements of the complaint.  

During the visit LPA collected staff schedules and observed and tested the function of external doors, interviewed 4 residents, 8 staff, a director and the administrator. LPA also toured restrooms, common areas, and a resident room.

On the allegation: Staff are not following residents admission agreements.
It was alleged that due to a lack of staffing the residents are not receiving weekly housekeeping and laundry services as stated in their admission agreements. Reporting party (RP) reported that residents are having to wash their own bedding when housekeeping is not available.
Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:	DATE: 10/01/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2025

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 3

Control Number 29-AS-20250924222649

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: 10/01/2025

NARRATIVE

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LPA reviewed admission agreement which states under section (h.) “The Oaks at Nipomo will provide routine weekly housekeeping services to your Apartment, including laundering sheets and towels.”

Interviews and records confirm the time frame for this concern started after 9/11/25. The facility employs four housekeepers. However, for a brief period, two housekeepers were unavailable due to valid personal reasons, one on extended medical leave and one due to an life-threatening emergency. Staff interviews indicated that while no temporary staff were hired due to State Licensing guidelines which delay background checks, overtime was offered to existing staff to help maintain services, including staff in other departments. The administrator confirmed that staff from other departments assisted with housekeeping duties during this time but declined the overtime to fully cover open shifts. The facility has hired another housekeeper who is currently going through the required background checks.

During interviews, report that routine housekeeping services were missed during the dates of 9/24/25 and 9/25/25, but the services were provided within 3 days of their routine date, and any resident needing services sooner were provided support within 24 hours. Residents interviewed did not state they were impacted by this temporary schedule, they have not heard of others stating they have any issues. There is no indication that the issue is ongoing or systemic. The facility made reasonable efforts to mitigate the impact of the staffing shortage, and there is no evidence that the facility willfully failed to uphold the admission agreement.

Although there was a brief disruption in routine housekeeping services due to an unforeseen staffing emergency, the facility took reasonable steps to address the issue. The evidence does not support a finding that the facility failed to follow the admission agreement in a manner that was systemic or intentional. Therefore, based on interviews, records reviewed and observation, the allegation is deemed to be Unsubstantiated at this time.

On the allegation: Facility doors are unsafe for residents in care.
It was alleged that the doors from the dining room to the patio door are difficult for the residents that use wheelchairs or walkers to open in either direction. RP also reported that several people have been hurt trying to get through the doors and that one resident almost fell going through the door last week. RP also reported that the residents have requested handicap accessible doors. RP also reported that residents have brought the issue to the administrator's attention repeatedly and have been told that the doors will not be changed. Continued on 9099-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:	DATE: 10/01/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20250924222649

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: 10/01/2025

NARRATIVE

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During resident and staff interviews the LPA found no confirmation that the doors have caused injury to any residents in care. On 9/30/25 LPA reviewed internal incident reports and incident reports provided to licensing for dates of 1/2/25 to 7/2/25 provided for another complaint and found that no reports of falls or injuries were due to the patio doors or any other external doors, total number of reports reviewed was 135.

LPA tested both sets of doors, found that they open smoothly and close at a slower rate. Resident interviews showed mixed opinions, with some stating the doors are light, but could be cumbersome or heavy for other residents. The facility confirmed they have had the same doors since licensure in 2018. Interview with residents provided that 2 out of 4 residents interviewed stated the doors were heavy for them.

While automatic doors would be a beneficial service to the community who widely use walkers and wheelchairs, the doors are not out of Title 22 regulation compliance. Administrator noted that if they tighten them to close at an even slower rate it would cause the tension to be so great, they would be hard to open. Staff interviewed stated that some residents want to be independent and will not ask for help opening the doors or will wave them away to prevent help, but staff, especially in the dining area do watch for residents and try to aid. Administrator was reminded the facility needs to ensure residents’ needs are met.

Based on records, interviews, and observations there is not a preponderance of evidence to prove the above allegations did or did not occur therefore the allegations are unsubstantiated at this time.

An exit interview was conducted. A copy of this report was provided.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:	DATE: 10/01/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2025

LIC9099 (FAS) - (06/04)

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