405809547-7-21-2026-29-AS-KBUY-DWG58K-20260729194403

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405809547
Report Date: 07/21/2026
Date Signed: 07/21/2026 04:58:06 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
04/02/2026 and conducted by Evaluator Melisa Rankin

COMPLAINT CONTROL NUMBER: 29-AS-20260402125617

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:	05:15 PM

ALLEGATION(S):

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

INVESTIGATION FINDINGS:

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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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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
04/02/2026 and conducted by Evaluator Melisa Rankin

COMPLAINT CONTROL NUMBER: 29-AS-20260402125617

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:	05:15 PM

ALLEGATION(S):

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Facility does not follow the menu

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rankin conducted a subsequent complaint visit to the facility above to issue final findings. LPA met with Ron Freeman Administrator and explained the purpose of the visit.

During the initial visit on 04/07/26 LPA Rankin interviewed administrator, culinary director, residents, and reviewed and collected copies of records. During the investigation, LPA Rankin conducted interviews with residents and staff, reviewed and collected relevant documentation, including menus, and meeting minutes for resident council. LPA also attended a Resident Council meeting.

On the allegation: Staff are not following weekly menu

It was alleged that residents report meals served in the dining room are often different from the items listed on the facility’s published weekly menu. Residents stated they have asked the facility to follow the posted menus but continue to observe substitutions for lunch and dinner items, including main courses. Residents also reported that menus sometimes are not finalized until the morning they are served.

Unsubstantiated

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)

Page: 6 of 7

Control Number 29-AS-20260402125617

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 08/07/2026 Section Cited CCR 87555(b)(18)	1 2 3 4 5 6 7	87555 (b)(18) General Food Service Requirements (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 is not met as evidenced by:	1 2 3 4 5 6 7	Facility has hired a new Culinary Director as of 7/21/26, the Regional Culinary Director will provide training. Facility has filled 7 culinary positions as of today. They are in the process of filling the remaining cook, server, and dishwasher positions to cover scheduled shifts.
	8 9 10 11 12 13 14	Based on interviews, observations, and record review, the licensee did not comply with the section above when staff were unable to meet residents’ needs, as evidenced by staff interviews, resident council feedback, and two prior citations related to kitchen operations. Additionally, 11 culinary staff members either resigned or were terminated within a 60 day period. These conditions posed a potential health and safety risk to residents in care.	8 9 10 11 12 13 14	Facility will provide LPA with Culinary Director Onboarding Outline and updated culinary staff roster by 8/7/26.
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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.

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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Control Number 29-AS-20260402125617

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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This issue was previously investigated under complaint #29-AS-20251119115422 in November 2025. During the prior complaint, LPA reviewed posted menus as well as revised “as served” menus, interviewed residents and staff, and discussed the facility’s menu planning system. The facility utilizes a software program called Grove, which is designed to ensure menus meet regulatory nutritional standards and provides structured guidance for menu planning and substitutions.

During the current complaint, LPA interviewed residents on 4/7/26, and during annual visit on 7/8/26 who stated that there have been times when items are not replenished, such as bacon, certain fruits, etc. and that a recent holiday event was advertised to have a specialized menu, but ended up offering BLT sandwiches and one specialized item. Other than the holiday event menu, when asked about menu concerns and changes, those interviewed did not have issue with the changes and stated that it is occasional.

LPA also reviewed resident council minutes from 2/18/25 to 6/16/26 there was new comments regarding requesting more variety in dinners and deserts and more replacement items being stocked in the bistro.

During annual visit on 7/8/26, LPA was informed by residents and staff that the culinary department experienced significant staffing changes within the last two months, including the resignation of the Culinary Director, the hiring and subsequent resignation of a new Culinary Director, the termination of a cook, and the resignation of additional culinary staff. Through interviews and review of documentation, LPA found that Directors and the Administrator have been filling in for cooks and servers to assist with meal service.

Title 22 regulations do not prohibit substitutions, provided menus are planned in advance, maintained on file, and overseen by qualified personnel. Menus posted and menus maintained on file met regulatory requirements. While residents reported occasional substitutions or uncertainty about meals until arriving in the dining room, the investigation found substitutions to be infrequent and within required nutritional standards.

Based on review of records, resident interviews, menu documentation, and regulatory requirements, the facility is in compliance with Title 22 regulations regarding menu planning and nutritional offerings. Therefore, this allegation is UNSUBSTANTIATED at this time.

Report discussed, and reports printed.

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-20260402125617

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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Title 22, Section 87555(b)(18), requires facilities to employ, train, and schedule sufficient food service personnel to meet resident needs. The previous complaint findings documented the delays were related to training and process inefficiencies and advised reassessment of staffing patterns and operational processes. Current observations, interviews, and record review demonstrate that the facility did not implement adequate corrective action. The absence of dishwashing staff on 03/21/26 and 03/22/26 and the ultimate separation of 11 staff further demonstrate breakdowns in scheduling and staffing management.

Based on interviews, observations, and record review, there is a preponderance of evidence that the facility has not employed, trained, or scheduled sufficient food service personnel to meet resident needs as required by Title 22. Therefore, the allegation is SUBSTANTIATED.

Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC9099-D).

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

Continued 9099-C
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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)

Page: 3 of 7

Control Number 29-AS-20260402125617

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

It was alleged that the facility has residents reporting unacceptable wait times for service in the dining room, including 20–30 minutes to receive food after waiting 10 minutes or more before orders are taken. This concern had previously been reported to facility management during complaint #29-AS-20251119115422. It was also alleged that on 03/21/26 and 03/22/26 there was no designated dishwasher staff, resulting in dirty dishes stacking up and requiring the use of paper plates. On 7/8/26 during annual visit, LPA was made aware of a complete staff turnover.

During the investigation, LPA reviewed resident council meeting minutes dated 2/18/25 through 6/17/26. Minutes consistently documented recurring concerns including wait times, temperature of food, service delays and times where there was only one server.

Administrator responses to the council include the following:
• On 8/19/25: “We are aware of this issue, and we are working on new solutions. Our prior work to address this issue has not been successful...”
• On 10/21/25: “We are struggling getting orders taken and food out in a timely manner that meets our resident's expectations. This is not a new issue, and we are disappointed we have been unable to solve this issue at this time. …working on a multi-prong strategy to make improvements. We also have some changes coming to the culinary program that will probably make this even more of a challenge…So, we will continue to work on improving our service and our service times.”
• On 1/22/26: stated concerns were being addressed through expectation clarification and training with culinary staff...

Resident interviews and review of resident council minutes confirmed that residents used the facility’s grievance processes, which include using suggestion boxes, discussing concerns with team members (i.e. Culinary Director during “Food for Thought” meetings), discussing concerns with the Executive Director/Administrator, and raising concerns at resident council meetings. Process also notes the option to refer concerns to the state Ombudsman or the local state agency.

Continued 9099-C
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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)

Page: 4 of 7

Control Number 29-AS-20260402125617

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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Evidence of change, improvement, or actionable responses was not observed. Residents have repeated similar concerns for at least the past year. The facility has a procedure for addressing resident grievances but these avenues have been unsuccessful. During Resident Council meeting on 7/21/26 LPA Rankin attended there were approximately 29 residents in attendance, the issue of staffing, items being out of stock, wait times, bistro are not being maintained were all re-discussed.

During prior complaint #29-AS-20251119115422 dated 11/25/25, LPA observed similar concerns. During that investigation, Administrator and Culinary Director stated the facility was actively working to improve communication, refine procedures, and streamline meal service operations. Continued complaints documented in resident council minutes following the complaint and recent interviews demonstrate that these issues have persisted.

During the annual inspection beginning 7/8/26, LPA learned that the Culinary Director resigned on 4/29/26 with a final day in community of 5/6/26 and a new Culinary Director began on 6/2/26, a cook was terminated on 6/15/26, and an additional 5 culinary staff resigned on 6/16/26. Following these separations the remaining 4 culinary staff resigned or were terminated over a period of 2-3 weeks, one due to personal reasons. The new Culinary Director then submitted resignation effective 7/16/26, but did not return to complete scheduled shifts.
Staff schedules and interviews confirmed that this series of departures resulted in culinary leadership and key kitchen staff positions becoming vacant. As a result, non-culinary staff such as Directors, the Administrator, Care Staff, Med Technicians, and the Maintenance Director have been regularly covering kitchen duties, and the facility required temporary culinary support from other Licensee operated facilities. In addition to the long-standing concerns regarding meal service delays, the significant breakdown in culinary staffing over the span of approximately two months further supports the allegations of this complaint.

During annual staff file review, LPA examined the records for the prior Culinary Director. A “Pathway to Success Plan” document dated 4/15/26 indicated the Culinary Director was going to be monitored due to performance concerns which noted areas regarding leadership, kitchen sanitation and cleanliness, food preparation, menus, resident satisfaction, and team member performance. LPA was informed that the Culinary Director resigned within weeks of this meeting. The cumulative impact of these staffing losses further affected the facility’s ability to meet Title 22 requirements.

Continued 9099-C
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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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