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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405809547
Report Date: 07/10/2026
Date Signed: 07/10/2026 04:45:09 PM

Document Has Been Signed on 07/10/2026 04:45 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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, THEFACILITY NUMBER:
405809547
ADMINISTRATOR/
DIRECTOR:		RONALD C. FREEMANFACILITY TYPE:
740
ADDRESS:177 MARY AVENUETELEPHONE:
(805) 723-5206
CITY:NIPOMOSTATE: CAZIP CODE:
93444
CAPACITY: 122CENSUS: 98DATE:
07/10/2026
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Megan Drap, DesigneeTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Rankin arrived at 8:40 a.m. to complete the 1-year annual visit to the facility above. LPA met with Megan Drap, Business Office Director and Designee and explained the purpose of the visit. LPA additionally collected documents for complaint # 29-AS-20260402125617.

Physical Plant & Environment Safety: LPA toured the Memory Care (MC) community. Resident rooms and bathrooms were observed in good condition, with operational fixtures, secured grab bars, and non-skid shower surfaces. Cabinets were locked, and disinfectants and cleaning solutions were inaccessible to residents at the time of the visit. Areas requiring lighting or minor maintenance were discussed with the Memory Care Director. The MC unit has secured, coded entry with delayed egress. During the visit, staffing consisted of 2 caregivers and 1 medication technician. The patio and courtyard areas provide adequate outdoor space and shade.



Incidental Medical & Dental: Medications stored in the MC medication cart were reviewed. Documentation is completed in the electronic Medication Administration Record (MAR) and the Centrally Stored Medication and Destruction Record (CSMDR). LPA reviewed 3 PRN medications for 2 residents and identified incomplete PRN documentation: Resident 4 (R4) had 13 of 28 doses not recorded, and Resident 5 (R5) had 6 of 11 doses not recorded. A citation was issued.
Continued on 809-C
NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Melisa Rankin
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/10/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 07/10/2026 04:45 PM - It Cannot Be Edited


Created By: Melisa Rankin On 07/10/2026 at 03:48 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: OAKS AT NIPOMO, THE
FACILITY NUMBER: 405809547

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(3)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above when Resident 4 (R4) and Resident 5 (R5) had PRN medications that were missing, presumed to be given, but the doses were not recorded which poses an immediate health, safety risk to persons in care.
POC Due Date: 07/13/2026
Plan of Correction
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Memory Care Directors (MCD) will review all PRN mediations and ensure count matches Medication Administration Records and that all doses are accounted for. The MCD will provide a written statement acknowledging audit of PRN medications and provide the steps to be taken to prevent recurrence, including retraining of staff responsible for medication handling.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Kelly Burley
NAME OF LICENSING PROGRAM MANAGER:
Melisa Rankin
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/10/2026 04:45 PM - It Cannot Be Edited


Created By: Melisa Rankin On 07/10/2026 at 03:48 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: OAKS AT NIPOMO, THE
FACILITY NUMBER: 405809547

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above when 9 packages of expired food items were discovered and 4 unsealed packages were found which poses a potential health and safety risk violation to residents in care.
POC Due Date: 07/31/2026
Plan of Correction
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Items were removed from storage. An audit and review of the full storage area will be done, facility will provide to the LPA the Inventory and Rotation procedures to manage ongoing review of food storage area.
Type B
Section Cited
CCR
87555(b)(27)
General Food Service Requirements
(27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above when kitchen area was found with debris, food particles, dirt, cooked food containing insects was found during annual inspection which poses a health and safety risk to persons in care.
POC Due Date: 07/17/2026
Plan of Correction
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Facility has a deep cleaning planned the week of 7/13/26, LPA will return to view kitchen area following the week of 7/17/26.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kelly Burley
NAME OF LICENSING PROGRAM MANAGER:
Melisa Rankin
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2026


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/10/2026
NARRATIVE
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Food Service: Culinary staffing has been reduced due to recent layoffs and resignations. Staff from other departments, including directors and the administrator, have been assisting. Residents interviewed stated they have not missed meals and noted changes but reported that staff are making visible efforts to meet their needs. During the visit, LPA observed 1 cook, 1 dishwasher, and 2 servers. Staffing concerns will be address in complaint # 29-AS-20260402125617.

During the kitchen tour, LPA observed expired food items in dry storage, including an item previously identified during a prior inspection, as well as open and unsealed packages of food that were cited during a complaint inspection dated 12/12/25. The walk-in refrigerator and freezer were clean, with properly covered items and temperatures within regulation. Flooring, shelving, and cooking equipment fronts were not clean and contained food particles and debris. A “proofing box” used to keep food warm was found turned off; when opened, it contained a tray of food that smelled like broccoli. According to the menu, broccoli was last served on 7/6/26 and 7/7/26. Unidentified flying insects were observed exiting the unit as the tray was removed. Two citations were issued.

Personnel Records & Training: Training records for 10 care giving staff were reviewed. Staff met required orientation and annual training hour requirements. Medication staff had annual hours for medication training. The administrator’s certificate is valid through 08/26/2027.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D.)

Exit interview completed, Appeal Rights given, and a copy of report printed for the facility.
NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Melisa Rankin
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2026
LIC809 (FAS) - (06/04)
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