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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405809547
Report Date: 11/25/2025
Date Signed: 11/25/2025 07:30:35 PM

Substantiated


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
11/19/2025 and conducted by Evaluator Melisa Rankin
COMPLAINT CONTROL NUMBER: 29-AS-20251119115422
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: 101DATE:
11/25/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ron FreemanTIME COMPLETED:
05:45 PM
ALLEGATION(S):
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The facility is storing expired food and failing to properly cover food items.

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rankin conducted an initial 10-day complaint visit to the facility above. LPA met with Ron Freeman and explained the purpose of the visit.

During the investigation, LPA Rankin conducted interviews with residents and staff, reviewed and collected relevant documentation, including menus, and meeting minutes for resident council. Toured kitchen and observed breakfast and lunch service and dinner preparation. LPA also attended a “Food for thought” discussion held by the Chef where residents came and discussed items, including concerns.

On the allegation: The facility is storing expired food and failing to properly cover food items.
It was alleged that the facility is serving expired food and that proper food storage practices are not being followed. During the visit at approximately 12:07 p.m., the LPA toured the facility’s walk-in refrigerator and dry goods storage area.
Continue on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2025
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 7
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
11/19/2025 and conducted by Evaluator Melisa Rankin
COMPLAINT CONTROL NUMBER: 29-AS-20251119115422

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: 101DATE:
11/25/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ron FreemanTIME COMPLETED:
05:45 PM
ALLEGATION(S):
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Facility kitchen is dirty.
Staff does not follow food menu for residents.
Facility has insufficient staff to meet the food service needs of the residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rankin conducted an initial 10-day complaint visit to the facility above. LPA met with Ron Freeman and explained the purpose of the visit.

During the investigation, LPA Rankin conducted interviews with residents and staff, reviewed and collected relevant documentation, including menus, and meeting minutes for resident council. Toured kitchen and observed breakfast and lunch service and dinner preparation. LPA also attended a “Food for thought” discussion held by the Chef where residents came and discussed items, including concerns.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2025
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 7
Control Number 29-AS-20251119115422
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: 11/25/2025
NARRATIVE
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On the allegation: Facility kitchen is dirty

It was alleged that the facility kitchen is not being maintained in a clean and sanitary condition. During the visit, the LPA conducted a comprehensive tour of the kitchen and dining areas. The following observations were made: A shelf located above the food preparation and hot holding areas had a visible layer of grime. Items stored on this shelf (metal pots, strainers, and plastic containers) were placed upside down, with rims in contact with the surface. A light buildup of grease was observed on top of the oven. Minor food residue was noted under the oven and food prep shelving; however, this was consistent with normal daily kitchen use.

All other areas of the kitchen—including the walk-in refrigerator, dry storage, prep counters, and general surfaces—were observed to be clean, well-organized, and maintained in a sanitary condition.


While minor cleanliness issues were observed, they did not rise to the level of a systemic or ongoing sanitation concern. The overall condition of the kitchen and dining areas was found to be clean and well-maintained. Based on the limited scope of the observations and the absence of any immediate health or safety risk, the preponderance of evidence standard was not met. Therefore, the allegation is unsubstantiated.

On the allegation: Facility has insufficient staff to meet the food service needs of the residents

It was alleged that the facility has insufficient staffing to meet residents’ needs related to food preparation and dining room service. During the visit, the LPA observed breakfast and lunch service, conducted staff interviews, attended a discussion with the chef and residents, and reviewed resident council meeting minutes. Based on observations at the time of the visit, staffing levels in the kitchen and dining room during meal periods appeared to be adequate.

Resident interviews and those who spoke during the discussion with the chef stated concerns regarding food not being served hot, wait times of 10–15 minutes to place an order, and overall service times ranging from 25 to 45 minutes. Continued on 9099-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 29-AS-20251119115422
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: 11/25/2025
NARRATIVE
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Staff interviews reflected mixed feedback. Some staff indicated that meal service runs more efficiently when specific cooks or team members are on duty, suggesting that individual performance impacts overall service quality. Consequently, there are periods when staffing and service delivery are sufficient, and other times when residents may experience delays.

Discussions with lead staff, as well as observations of the dialogue between residents and the chef, indicate that the facility is actively working to improve communication, refine procedures, and streamline meal service operations. At this time, concerns regarding food temperature and service delays do not appear to be directly related to staffing levels, but rather to training and process inefficiencies. This was discussed with management during the visit.


While the facility was found to be in compliance at the time of the visit, it is recommended that the facility continue to assess staffing patterns and enhance operational processes to ensure consistent and timely meal service.

Based on observations and interviews, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur. Therefore, the allegation is UNSUBSTANTIATED.

On the allegation: Facility failed to serve meals as planned and posted on the menu

It was alleged that the facility does not consistently serve meals as listed on the posted weekly menus. During the visit, LPA reviewed facility menus, both those posted and the revised, "as served menus", interviewed residents and staff, and discussed the facility’s food service system. The facility utilizes a software system called Grove, which is designed to ensure meals meet regulatory nutritional standards and provides structured guidance for menu planning and substitutions.


Title 22 regulations do not prohibit substitutions, provided menus are planned in advance, and maintained on file. Menus posted and copies are maintained on file as required. While some residents reported occasional substitutions or not knowing what would be served until arriving in the dining room, the investigation found that, substitutions were infrequent and generally comparable to the originally planned menu items. Per interviews the sides and deserts were the most common changes. Continued 9099-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 29-AS-20251119115422
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: 11/25/2025
NARRATIVE
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However, for improved resident satisfaction, it is recommended that the facility enhance communication regarding menu changes—such as posting or announcing substitutions prior to meal service, whenever feasible.


Based on a review of the regulation requirements and the facility being in compliance with applicable regulations regarding menu planning and nutritional offerings. This allegation is unsubstantiated at this time.

Exit interview conducted, and a copy of this report issued.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 29-AS-20251119115422
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: 11/25/2025
NARRATIVE
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In the walk-in refrigerator, the LPA initially observed an uncovered container of breakfast sausage links. Upon a second walkthrough, the container had been removed; however, an open, unsealed package of sausage patties was noted. All other food items in the walk-in appeared fresh, no odors or mold was observed and all were properly labeled and covered.

In the dry storage room, five food items were found with expiration dates labeled “best by” or “use by” September 2025, indicating they were past their recommended shelf life. Additionally, two packages—one of spaghetti and one of cereal—had visible holes, with food spilling out. A container of raisins, not stored in its original packaging, was covered with plastic wrap that had a hole approximately the size of a quarter. Photographs were taken to document the observed items.

These findings are not in compliance Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC9099-D). Section 87555(b)(28), which requires that All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery.

Based on LPAs observations, the presence of expired and improperly stored food poses a potential health and safety risk to residents. The preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED.

Report discussed, and copies of appeal rights and reports printed.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 29-AS-20251119115422
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/12/2025
Section Cited
CCR
87555(b)(28)
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General Food Service Requirements 87555 (b)(28)All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery. This requirement is not met as evidenced by:
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Items were immediately removed from storage. Disaplinary action for the staff responsible for this area. Training will be conducted and a copy of the training will be supplied to LPA by 12/12/25.
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Based on observation the licensee did not comply with the section cited above when food items were discovered improperly stored, opened, and expired, which poses a potential health and safety risk or personal rights violation to residents in care.
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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.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 7