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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405809547
Report Date: 08/26/2026
Date Signed: 08/26/2026 02:56:41 PM

Document Has Been Signed on 08/26/2026 02:56 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: 94DATE:
08/26/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:05 AM
MET WITH:Theresa Egurrola DesigneeTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Melisa Rankin conducted an unannounced Case Management Deficiency visit in conjunction with complaint visit ( # 29-AS-20260821134127). LPA met with facility Designee, Theresa Egurrola. The purpose of this report is to issue a citation for deficiencies observed during the complaint investigation which were not related to the complaint allegations.

On 8/26/26 at approximately 8:15 a.m. LPA entered the kitchen, stopped in the prepping area where there is a sink, counter space, and shelves. On the bottom shelf were 2 plastic bins with onions. Upon inspection, LPA found 18 yellow onions with approximately 8 of them starting to rot, they were splitting open, mushy, and when moved, 2 small bugs flew out from the bin. The second bin of purple onions appeared to be fine. Images of the onions and flies were taken. The observation noted above is also on the complaint report, but relevant to this case management visit.

LPA then went into the walk-in refrigerator and freezer area at approximately 8:26 a.m. and found the following: In the refrigerator there was thawed shrimp in a metal container with saran wrap over it, the date stated “7-30”, when tipped there was a foggy grey liquid in the bottom of the container. A broken plastic container dated “7-30” with black bean humus, unknown how long the container has been broken and food item has been exposed. Green leaf items, believed to be cilantro were in a sealed bag, but the produce has started to turn brown and yellow in some areas. In the freezer area, LPA also observed 3 open/unsealed/uncovered packages, the items were breaded chicken strips, what appeared to be spring rolls, and breaded mozzarella sticks.

Continue on 809-C

Kelly Burley
Melisa Rankin
DATE: 08/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
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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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: 08/26/2026
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At approximately 8:40 a.m. LPA walked into the kitchen area near the drink dispenser and where packages of bread is stored. LPA found unsealed/open packages of hot dog and hamburger buns. The last time these items would have been an option for the menu would have been during the dinner meal on 8/25/26. It is probable that the items have been open for at minimum 12 hours based on mealtimes from the evening before and the morning time they were observed.

At approximately 8:42 a.m. LPA went into the dry storage and found another package of hot dog buns opened, and by touch through the packaging, there were buns that were starting to stiffen. LPA also found a box of rice, and penne pasta, opened and unsealed.

On 11/25/26 a complaint regarding expired and opened packages was completed and the facility was cited, similar issue, but different regulation was cited on 7/10/26 during the annual review. Based on the Repeat Violation from the 11/25/26 citation and the concern of contamination of spoiled onions, and expired shrimp this civil penalty for a repeat violation for $250 is assessed.

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

A copy of the report and appeal rights was printed and left for the facility.

Note the pre-populated information on this form have a prior administrator's name from the Community Care Licensing Software system in error and cannot be updated during this visit.

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

DATE: 08/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/26/2026 02:56 PM - It Cannot Be Edited


Created By: Melisa Rankin On 08/26/2026 at 01:33 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: 08/26/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/18/2026
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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Facility will clean all surfaces, especially in walk-in refrigerator/freezers. LPA will return to view kitchen area to clear citation. LPA will give the facility 7 days from today before conducting the citation clearance visit specific to the culinary department.
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Based on observation, the licensee did not comply with the section cited above when they failed to properly store, and dispose of food in the kitchen area, leaving packages opened, and rotting or expired items in refrigerated areas, which poses a potential health and safety risk 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.
Kelly Burley
NAME OF LICENSING PROGRAM MANAGER:
Melisa Rankin
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2026


LIC809 (FAS) - (06/04)
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