405809547-8-28-2024-29-AS-KBUY-D8MVRB-20240830163940

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405809547
Report Date: 08/28/2024
Date Signed: 08/28/2024 12:40:46 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
12/04/2023 and conducted by Evaluator Rachael De Leon

COMPLAINT CONTROL NUMBER: 29-AS-20231204161250

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: 108	DATE:	08/28/2024
		UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Ronald "Ron" Freeman, Administrator		TIME COMPLETED:	12:50 PM

ALLEGATION(S):

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The facility apartments not being kept clean and free from odors.
Facility staffing is not sufficient in dining to meet the needs of the residents

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 with Ron Freeman, Administrator and explained the purpose of the visit.

LPA De Leon conducted the initial complaint visit on 12/11/2023 toured the 2nd floor, requested records, conducted interview with staff at 11:05am, 11:30am, 11:45am, 12:00pm, 12:30pm, 12:45pm, 1:00pm and 1:30pm and residents at 2:52pm and 3:00pm.

On the allegation: The facility apartments not being kept clean and free from odors. LPA conducted interviews with staff and residents which revealed a 2nd floor apartment had foul odors. On 04/29/2024 an incident report was provided to LPA Miller that R1 was transported to the hospital for mental health evaluation. Administrator stated R1 did not return to the facility after that date.
Continued 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024

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 3

Control Number 29-AS-20231204161250

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: 08/28/2024

NARRATIVE

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The facility ruled unsanitary living conditions and the Fire Chief deemed the room a bio hazard, A bio hazard cleaning crew was brought in to remove the bio hazard and clean the room.

Resident 1 (R1) was issued an eviction on 05/30/2024 with the following dates of noncompliance to keep room clean and free from odors 11/15/2023, 12/11/2023, 02/06/2024, 02/29/2024, 03/21/2024, 03/24/2024, 04/29/2024 along with multiple other dates ranging from 02/24/2024-03/19/2024 with refusals of care needs, room cleaning, and laundry services. Based on the evidence this allegation is deemed Substantiated at this time.

On the allegation: Facility staffing is not sufficient in dining to meet the needs of the residents. LPA interviewed staff and residents which revealed the dining room staffing is getting better but still short a few positions, dishwasher, busser and server. Staff stay late or staff come in early when they can. The staff call offs are what make the dining room short staffed when no one can cover the shift. Staff have had to work shorthanded, and the wait times can increase for residents. Staff stated you can’t look at the schedule because it does not reflect for call offs or no shows so you really can’t tell if the kitchen is short staffed by looking at the schedules.

Facility census was 98 residents on 08/24/2023. LPA emailed Administrator on 08/29/2023 and asked what it looks like if the kitchen and dining are fully staffed. Administrator stated 1 AM cook, 2 AM servers, at 11:00am the PM staff of 1 dishwasher and 1 additional server come in for lunch and the PM service, 1 PM cook and 1-2 more servers for dinner.

LPA De Leon reviewed the staff schedules for 12/01/2023-12/11/2023 for kitchen/dining staff. The facility census was 108 residents on 1/11/2023. On 12/02/2023 the facility was short 1 am server, on 12/03/2023 the facility was short staffed 1 am server, on 12/04/2023 the facility was short staffed 1 am server, on 12/05/2023 the kitchen was short staffed 1 cook in the pm, on 12/10/2023 the kitchen was short 1 am server, and on 12/11/2023 the kitchen was short staffed 1 am server. Staff stated the Food Service Director/ Chef does help cover positions when the facility is short staffed but not all the time. Based on the evidence this allegation is deemed Substantiated at this time.

Exit interview conducted, copy of report and appeal rights printed for Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20231204161250

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: 08/28/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/04/2024 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	(a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator agreed to give invoices for the clean up of the bio-hazard and any other invoices for cleaning and sanitizing R1’s apartment.
	8 9 10 11 12 13 14	Based on interviews and records the Licensee failed to comply with the regulation above, R1 was living in unsanitary living conditions which posed a potential health, safety and personal rights risk to residents in care.	8 9 10 11 12 13 14
Type B 09/04/2024 Section Cited CCR 87555(b)(18)	1 2 3 4 5 6 7	(b)The following food service requirements shall apply:(18)Sufficient food service personnel shall be employed, trained and their working hours scheduled to meet the needs of residents. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator agreed to provide LPA 1 month of schedules and the time clock hours actually worked for all kitchen staff for the month of August of 2024. Provide how many staff and positions for a fully staffed kitchen with a census of 100 residents and an up to date LIC 500.
	8 9 10 11 12 13 14	Based on interviews and record review the Licensee did not comply with the regulation above, Residents have longer wait times in dining room when the kitchen staff are shorthanded which poses a potential personal rights risk to residents in care.	8 9 10 11 12 13 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 Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024

LIC9099 (FAS) - (06/04)

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