405809547-7-21-2021-29-AS-KBUY-C56N9S-20210722101624

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405809547
Report Date: 07/21/2021
Date Signed: 07/21/2021 02:59:08 PM

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
11/08/2019 and conducted by Evaluator Rachael De Leon

COMPLAINT CONTROL NUMBER: 29-AS-20191108115918

FACILITY NAME:	OAKS AT NIPOMO, THE		FACILITY NUMBER:	405809547
ADMINISTRATOR:	CONNELLY, JANICE E.		FACILITY TYPE:	740
ADDRESS:	177 MARY AVENUE		TELEPHONE:	(805) 723-5206
CITY:	NIPOMO	STATE: CA	ZIP CODE:	93444
CAPACITY:	122	CENSUS: 78	DATE:	07/21/2021
		UNANNOUNCED	TIME BEGAN:	01:11 PM
MET WITH:	Donahue Vanderhider, Administrator		TIME COMPLETED:	02:27 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff was not providing services noted for resident

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 allegations. LPA met with Administrator Donahue Vanderhider and explained the purpose of the visit.

During the investigation, LPA conducted interviews with staff on 11/14/2019 at 1:30pm, LPA was unable to conducted interviews with residents due to cognitive awareness in the memory care (MC) unit. LPA conducted interviews with witnesses on 06/22/2021 at 11:03am and 2:22pm and on 07/20/2021 at 10:39 am, 11:19 am, 12:08 pm and 12:35pm. LPA reviewed records on 11/14/2019 at 3:30pm, 07/09/2021 at 3:00 PM and 07/20/2021 at 5:00pm.

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: 07/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021

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

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
11/08/2019 and conducted by Evaluator Rachael De Leon

COMPLAINT CONTROL NUMBER: 29-AS-20191108115918

FACILITY NAME:	OAKS AT NIPOMO, THE		FACILITY NUMBER:	405809547
ADMINISTRATOR:	CONNELLY, JANICE E.		FACILITY TYPE:	740
ADDRESS:	177 MARY AVENUE		TELEPHONE:	(805) 723-5206
CITY:	NIPOMO	STATE: CA	ZIP CODE:	93444
CAPACITY:	122	CENSUS: 78	DATE:	07/21/2021
		UNANNOUNCED	TIME BEGAN:	01:11 PM
MET WITH:	Donahue Vanderhider, Administrator		TIME COMPLETED:	02:27 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Lack of supervision resulting in a resident sustaining injuries from multiple falls
Staff is not responding promptly to residents alerts.
Resident was able to wander from the facility

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 allegations above. LPA met with administrator Donahue Vanderhider and explained the purpose of the visit.

During the investigation, LPA conducted interviews with staff on 11/14/2019 at 1:30pm, LPA was unable to conducted interviews with residents due to cognitive awareness in the memory care (MC) unit. LPA conducted interviews with witnesses on 06/22/2021 at 11:03am and 2:22pm and on 07/20/2021 at 10:39 am, 11:19 am, 12:08 pm and 12:35pm. LPA reviewed records on 11/14/2019 at 3:30pm, 07/09/2021 at 3:00 PM and 07/20/2021 at 5:00pm.

Continued 9099-C

Unsubstantiated

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: 07/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 29-AS-20191108115918

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: 07/21/2021

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

On the allegation: Lack of supervision resulting in a resident sustaining injury from multiple falls. LPA De Leon conducted interviews with staff and witnesses which revealed that Resident 1 (R1) did have witnessed and unwitnessed falls. R1 was not paying for additional services for the facility to provide R1 with one on one care by facility staff. According to interviews with Witness 1 (W1) and Witness 2 (W2) R1 fell even when visitors and private care staff were present in the room and pull cords were used to notify staff. Staff response to R1’s room according to records on 10/31/2021 was at 4:03pm cleared in 11 minutes and at 5:56pm cleared in 2 minutes. The facility did submit incident reports for R1’s falls to Community Care Licensing (CCL) as required. According to interviews, pull cord records, and facility incident reports, the facility answered alarms on pull cords, called 911 when needed and followed instructions given, therefore the allegation is deemed unsubstantiated at this time.

On the allegation: Staff is not responding promptly to residents’ alerts. LPA De Leon interviewed staff and witnesses which revealed that many of the residents did use the pull cords for help. According to W2 interview R1 was not able to pull the pull cord for help on own and W2 was present in the room and used the pull cord to get help from staffing. Record review showed two pull cords for R1 in 10/31/2021, one call was answered in 2 minutes and 1 call was answered in 11 minutes, according to the pull cord alarm records staff did have about 5 calls around the same time and helped residents as soon as they could. The pull cord records were reviewed, and most calls were answered within 10 minutes. Record review only showed 10 out of 160 pulls cord calls from 10/31/2021-11/09/2021 in the memory care unit to be longer than 10 minutes. Staff (S1-S4) interviews revealed that calls are answered in 10 minutes or less, some calls may take longer due to staff assisting with other residents but staff do try to finish up and get to the next call as quickly as they can and pull cord alarms notify other personal when it is not answered timely so others can assist. Based on record review the allegation is deemed unsubstantiated at this time.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 29-AS-20191108115918

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: 07/21/2021

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

On the allegation: Resident was able to wander from the facility. LPA De Leon interviewed staff and witnesses no interviews revealed of any of the MC residents wandering away from the facility. LPA reviewed incident reports for this facility and observed no incident reports about a resident wandering away from the facility on 10/31/2021. The memory care unit has delayed egress with alarms that sound. Staff are trained to respond immediately if the delayed egress alarms sound. The interviews with staff or residents did not provide any evidence that this allegation occurred therefore, this allegation is deemed unsubstantiated at this time.

Exit interview conducted, copy of report emailed to Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 29-AS-20191108115918

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: 07/21/2021

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

On the allegation: Staff was not providing services noted for resident. LPA conducted interviews with several witnesses which revealed residents where not getting showered according to their contracts and shower schedules. The memory care unit (MC) had 18 residents at that time and facility admission agreements covered 1 shower per week and according to Witnesses 1-6 (W1-W6) those showers were not being provided according to contract and shower schedule. W1-W2 paid the facility additional care fees to provide showers 7x a week and those showers where not being provided to R1 on a regular basis. W1-W2 provided contact information to facility in case R1 refused showers to notify W1-W2 so they could come to the facility and help with facilitating a shower for R1, W1-W2 were not being notified of shower refusals. W2 asked to review the shower scheduled after arriving and resident did not look showered, smelled, hair was greasy, and clothes were dirty. Shower schedule stated the resident had been showered and signed off, but W2 had observed the resident did not appear to have been showered that day at all, hair was greasy, not combed and clothes were dirty. W2 discussed this with MC head nursing Staff 5 (S5) to show the schedule was incorrect and R1 clearly did not take a shower that day. W1-W6 stated residents did not look showered, hair was not being brushed or washed, oral hygiene was not being provided, and residents were not wearing clean clothes. LPA made 3 requests to the facility for a copy of the resident’s shower schedule/refusal records and the facility was unable to provide those records to LPA, therefore this allegation is deemed substantiated at this time.

Exit interview conducted, deficiency cited, copy of report and appeal rights emailed to Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021

LIC9099 (FAS) - (06/04)

Page: 6 of 6

Control Number 29-AS-20191108115918

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: 07/21/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/23/2021 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	...(f)Basic services shall at a minimum include:(1)Care and supervision as defined in Section 87101(c)(3) and ... section 1569.2(c). This requirement was not met evidenced by:	1 2 3 4 5 6 7	Administrator agreed to make a shower schedule for the MC residents and provide a copy of the schedule to residents & RP. Facility agrees to employ enough staff to keep the shower schedule
	8 9 10 11 12 13 14	Based on W1-W6 interviews and lack of records to review the licensee did not comply, facility was not providing showers to residents on a regular basis per contracts which poses a potential personal rights risk to resident in care.	8 9 10 11 12 13 14	without interruption, all refusals must be documented and families must be notified. Provide all documentation to CCL.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 07/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 6