405809547-7-21-2026-29-AS-KBUY-DWG56V-20260729194121

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405809547
Report Date: 07/21/2026
Date Signed: 07/21/2026 01:12:52 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
07/08/2026 and conducted by Evaluator Melisa Rankin

COMPLAINT CONTROL NUMBER: 29-AS-20260708123103

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: 100	DATE:	07/21/2026
		UNANNOUNCED	TIME BEGAN:	09:47 AM
MET WITH:	Ron Freeman, Administrator		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff sleeping while on duty

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rankin conducted a subsequent complaint visit to issue final findings on this investigation. LPA met with Ron Freeman and explained the purpose of the visit. During the investigation, LPA conducted an initial visit on 7/9/26 where LPA conducted an interview with a director.

Allegation: Staff sleeping while on duty

It was alleged that overnight staff were sleeping while on duty and that a supervisor was aware of the issue.
On 7/10/26, during the annual review, the LPA requested and reviewed thirteen (13) staff files, ten (10) of them were overnight staff, or staff noted to have covered recent overnight shifts. No records regarding staff sleeping were found.
The LPA interviewed three Directors. All initially reported that they were not aware of current concerns regarding staff sleeping. Each stated that when such issues are brought to their attention, they take immediate corrective action due to resident safety concerns.

Continue on 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2026

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

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20260708123103

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: 07/21/2026

NARRATIVE

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Later in the afternoon on 7/10/26, a director revealed that after a brief inquiry it was found that Staff 1 (S1) was observed sleeping during the overnight shift of 7/9/26 and had announced this during the morning huddle. The Director reported that S1 was contacted and admitted to sleeping on duty. The Director stated that S1 would be terminated for failing to follow facility policy and due to concerns for resident safety.

The LPA verified the termination through viewing a “Corrective Counseling Documentation” dated 7/12/26, and a Termination Notice confirming termination effective 7/12/26.

Sleeping while on duty violates the licensee’s requirements. The Licensee “Caregiver…Job Description” documents state “NOC shift caregivers must stay awake…”. Because the licensee bases their staffing levels on the ratio of residents who require assistance, the licensee determined that the assigned level of staffing was necessary to meet resident needs, especially in the memory care unit where the staff member was scheduled.

LPA did not find evidence that management knew of or know of staff who sleep on duty.

A separate allegation of staff sleeping was reported in a prior complaint in December 2025 (Complaint Control #29-AS-20251201150209). In that complaint, sleeping staff were alleged to have contributed to a resident elopement; however, the allegation was unsubstantiated as the cause. The presence of a recent, confirmed incident of a staff member sleeping on duty lends to a potential pattern by staff.

Based on interviews and records reviewed, the allegation that staff were sleeping while on duty is found to be substantiated. Although the facility responded promptly and took corrective action by terminating the staff member, sufficient evidence exists to confirm that the violation occurred. The allegation is therefore deemed SUBSTANTIATED.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D).

Copy of report, Appeal Rights, were printed and given to the administrator.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2026

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20260708123103

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: 07/21/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/24/2026 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The facility on 7/12/26 took corrective action and terminated staff. Facility to issue a staff memo reminding staff of expectations and not being allowed to sleep on duty. Copy of memo to be submitted to LPA by 7/24/26.
	8 9 10 11 12 13 14	Based on an interview, and record reviews, the licensee did not comply with the section cited above when a Night caregiver staff slept during their night shift which violates licensee’s policies and poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	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
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2026

LIC9099 (FAS) - (06/04)

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