405809547-8-26-2026-29-AS-KBUY-DXG3QB-20260830182652

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405809547
Report Date: 08/26/2026
Date Signed: 08/26/2026 02:45:09 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
08/21/2026 and conducted by Evaluator Melisa Rankin

COMPLAINT CONTROL NUMBER: 29-AS-20260821134127

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: 94	DATE:	08/26/2026
		UNANNOUNCED	TIME BEGAN:	08:05 AM
MET WITH:	Theresa Egurrola, Designee		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff do not ensure the facility is clean and sanitary

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Melisa Rankin conducted an initial 10-day complaint visit to the facility above. LPA met with Designee signer Theresa Egurrola, and explained the purpose of the visit.

During the visit LPA toured the kitchen, bistro, and dining area. Took images of all areas observed and collected relevant documents. LPA also re-toured the kitchen area with the designee and the Culinary Director to provide notes regarding areas of concern.

Allegation: Staff do not ensure the facility is clean and sanitary

It was alleged that the kitchen is not being cleaned, that items of food and food debris were on the floor of the freezer and walk-in refrigerator, as well as the dining room carpet is heavily soiled and stained and food articles are under the dining room tables. Continue on 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR 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

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-20260821134127

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: 08/26/2026

NARRATIVE

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On 8/18/26 LPA was provided images of areas of concern which show a package of closed Hawaiian Rolls, blackened bananas and food particle crumbs on the freezer floor, as well as liquid spills and a yogurt container on the floor of the dry storage area, and food items on a carpeted area that appears to be under a dining table.

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 insects flew out from the bin. The second bin of purple onions appeared to be fine. Images of the onions and video of the flies were taken.

LPA then went into the walk-in refrigerator and freezer area at approximately 8:26 a.m. and found the following: In the freezer area, under the shelves in the far-left corner there was still the package of Hawaiian Rolls, and behind that the black bananas, proof that they had been there since the original images from 8/18/26. On the floor was spilled ice cream about 6 inches in diameter below 4 tubs of ice cream. Also noted were the freezer door and hinges, observed from the refrigerator section that leads into the walk-in freezer was uncleaned, areas of white and black particles were observed.

LPA observed the dining room at 1:55 p.m. and found many areas, some spotted, some larger in diameter where prior spills had occurred and a stain had remained. A few areas had crumbs, but it was also following lunch and the kitchen staff were cleaning, no unreasonable amount of debris were on the dining room floor during time of visit.

Continue to 9099-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR 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

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20260821134127

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: 08/26/2026

NARRATIVE

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On 7/10/26 during the annual visit LPA cited the facility for the cleanliness of the kitchen, as well as the observation of a insects when food had not been properly disposed of.

Other areas of concern regarding food storage management is being addressed on a Case Management.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D). A civil penalty for a repeat violation for $250 is being assessed.

Based on observation, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED.

Copy of report and appeal rights printed and provided to 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.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR 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

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 29-AS-20260821134127

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: 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)(27)	1 2 3 4 5 6 7	87555 General Food Service Requirements (b) (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	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.
	8 9 10 11 12 13 14	Based on observation, the licensee did not comply with the section cited above when they failed to clean the freezer remove food items that attracted insects, left food items on the freezer floor for 8 plus days, not regularly clean and wipe down areas inside of walk-in refrigerated areas, which poses a potential health and safety risk violation 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: 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

LIC9099 (FAS) - (06/04)

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