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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405809547
Report Date: 08/12/2026
Date Signed: 08/12/2026 03:32:06 PM

Document Has Been Signed on 08/12/2026 03:32 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: 84DATE:
08/12/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:57 AM
MET WITH:Megan DrapTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Melisa Rankin conducted an unannounced case management visit at 8:58 a.m. LPA was also conducting investigations for complaint numbers #29-AS-20260805124058 and #29-AS-20260801171938. The reason for the Case Management visit is to investigate a concern reported to the LPA during the complaint interviews as well as to follow up on a self-reported incident received on 08/03/2026.

During this investigation LPA conducted file reviews, reviewed Medication Administration Records (MAR) and Centrally Stored Medication and Destruction Records (CSMDR), and obtained copies of these documents. LPA conducted interviews, and documents collected verified the events occurred. Interview with staff, and Memory Care Director were done on 8/6/26 during visit for the 2 complaints. Additional interviews were conducted during today’s visit.

The self-report pertains to a medication error regarding Resident 1 (R1). The report was documented on a LIC 624 Unusual Incident/Injury Report form. Report stated that R1 was "given 10 daily doses out of 14 of Adelondrate 70mg weekly dose." Upon review of records, LPA discovered 7/14/26 to 7/25/26 R1 received the medication almost daily, the exception being 7/18/26 and 7/24/26. The medication is ordered to be given "1 TABLET BY MOUTH WEEKLY...". Interviews on 8/6/26 state that the medication error was a combination of the MAR not being properly approved in the system to prompt the medication to only show up 1 time a week, and the additional error was based on Medication Technicians not re-checking the label prior to giving the medication each day.

Continue on 809-C

Kelly Burley
Melisa Rankin
DATE: 08/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2026
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 08/12/2026 03:32 PM - It Cannot Be Edited


Created By: Melisa Rankin On 08/12/2026 at 07:58 AM
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: 08/12/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/14/2026
Section Cited
CCR
87465(a)(4)

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87465 Incidental Medical and Dental Care (a) A plan for incidental medical...care shall be developed by each facility. The plan shall encourage routine medical... care and provide for assistance in obtaining such care, by compliance with the following: (4)The licensee shall assist residents with self-administered medications as needed.
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Administrator, Residential Service and Memory Care Directors have addressed the issues with R1, write ups done following the discovery and training was completed.
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This requirement is not met as evidenced by:
Based on interview and record review, the licensee did not comply with the section cited above as Resident #1 (R1) received dosses of a medication ordered as 1 time weekly, but was given daily and Resident #2 (R2) was administered Resident 3’s (R3)’s medications for 6 plus days. This posed an immediate health and safety risk to people in care.
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Pro-actively processes including obtaining refill approvals earlier have been started and a call with the pharmacy regarding the issue for R2's delay in medication is being disussed on 8/13/26 and a summary of the plan moving forward will be provided to the LPA by the moring of 8/14/26.

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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.
Kelly Burley
NAME OF LICENSING PROGRAM MANAGER:
Melisa Rankin
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2026


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: 08/12/2026
NARRATIVE
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The second report alleged that Resident 2 (R2) ran out of the medication Creon and did not receive a replacement refill for 6 days. During the 6 days Resident 3 (R3) allowed their medication to be used for R2 until the refill was obtained. Interviews were conducted, copies of the MAR and CSMDR were collected. The reports show the medication reported was started on 6/1/26 and was last given 6/18/26. It shows that the new prescription of Creon was started 6/25/26. The facility changed pharmacies, it was expected that the medication would arrive on cycle refill on 6/19/26, the facility was asked to provide documentation of when they reached out to the pharmacy when it did not arrive on cycle, the facility provided documentation of requests to obtain refills from the pharmacy starting on 6/22/26.

LPA did a count of the days the medication should have covered for the resident, based on 200 pills, where 6 pills are used per day, the medication that was started 6/25/26 should have ran out on or around 7/28/26. It is unclear how the resident had enough pills to last through to 8/1/26. The resident ran out of Creon again on/or around the first part of August. Interview from R3 stated it was 8/3/26 and 8/4/26 where again R2 needed to use medication from R3’s supply.

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 conducted, copy of appeal rights and report were printed.

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Melisa Rankin
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2026
LIC809 (FAS) - (06/04)
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