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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405809547
Report Date: 05/20/2022
Date Signed: 05/20/2022 03:55:33 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
05/17/2022 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20220517083341
FACILITY NAME:OAKS AT NIPOMO, THEFACILITY NUMBER:
405809547
ADMINISTRATOR:TRACY S. FLAHERTYFACILITY TYPE:
740
ADDRESS:177 MARY AVENUETELEPHONE:
(805) 723-5206
CITY:NIPOMOSTATE: CAZIP CODE:
93444
CAPACITY:122CENSUS: 108DATE:
05/20/2022
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Tracy Flaherty, AdministratorTIME COMPLETED:
03:57 PM
ALLEGATION(S):
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Staff is not following COVID-19 guidelines.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) De Leon conducted a 10-day Complaint visit to the facility. LPA met with Tracy Flaherty Administrator and explained the purpose of the visit.

On the allegation: Staff is not following COVID-19 guidelines. LPA De Leon recieved a statement that Witness 1 (W1) visited the facility on the evening of 5/13/2022 around 5:00 PM, W1 observed a staff (S1) whom appeared to be serving food not wearing mask correctly. The mask was below S1's chin. S2 stated W1 informed S2 and S2 did engage with S1 infroming S1 that it is necessary to wear mask correctly at all times. S2 stated S1 had a mask and was not sure if S1 was wearing it properly or not at the time. S2 stated they explained to staff it is required and staff will be wrote up for non-compliance. Based on the evidence this allegation is deemed Substantiated at the time.
Exit interview conducted, deficiency cited, copy of report and appeal rights given.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 29-AS-20220517083341
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: OAKS AT NIPOMO, THE
FACILITY NUMBER: 405809547
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/20/2022
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents...: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:
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Administrator agreed to hold infectious control training with masks requirments in the faciliy and provide proof of training with staff signatures.
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Based on W1 the licensee did not comply with regulation above 1 staff was present in the facility kitchen without wearing the mask properly which poses an immediate Personal Rights risk 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.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022
LIC9099 (FAS) - (06/04)
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