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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405809547
Report Date: 11/10/2022
Date Signed: 11/10/2022 06:17:38 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
07/21/2022 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20220721130540
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: 101DATE:
11/10/2022
UNANNOUNCEDTIME BEGAN:
05:25 PM
MET WITH:Tracy Flaherty, AdministratorTIME COMPLETED:
06:14 PM
ALLEGATION(S):
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8
9
Licensee did not ensure that changes in the resident were brought to the attention of resident's responsible person in a timely manner.
Licensee did not ensure that changes in the resident were documented.
Staff did not meet the resident's hygiene and/or showering needs
Staff did not meet the resident's incontinence needs.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above to deliver final findings of the investigation. LPA met with Tracy Flaherty, Administrator and explained the purpose of the visit.
LPA De Leon conducted the initial complaint visit on 07/26/2022. LPA conducted interviews with staff on 09/14/2022 around 4:00pm and on 11/07/2022 at 4:34pm, 5:29pm, 6:29pm, 6:51pm, and 7:15pm. LPA conducted interviews with residents on 11/02/2022 at 3:03pm, 11/04/2022 at 1:41pm, 1:47pm, 1:54pm, 4:30pm, and on 11/07/2022 at 4:02pm. LPA conducted interviews with witnesses on 11/02/2022 at 3:20pm, 4:00pm, 5:15pm, on 11/03/2022 at 5:27pm, on 11/04/2022 at 4:50pm, and on 11/07/2022 at 2:44pm, 3:29pm, and 3:48pm. LPA collected records on 01/26/2022, 07/26/2022, 09/14/2022 and 11/09/2022. LPA reviewed records on 10/31/2022, 11/02/2022, 11/03/2022, 11/04/2022 and 11/09/2022.

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: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022
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 6
Control Number 29-AS-20220721130540
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
VISIT DATE: 11/10/2022
NARRATIVE
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On the allegation: Licensee did not ensure that changes in the resident were brought to the attention of resident's responsible person in a timely manner. LPA conducted interviews with witnesses which revealed 5/8 witnesses stating the communications concerning residents and their care has not been timely or has not been communicated at all to responsible parties. Based on the evidence this allegation is deemed Substantiated at this time.
On the allegation: Licensee did not ensure that changes in the resident were documented. LPA interviewed witnesses and staff which revealed 5/8 witnesses requested records or documentation that was not provided to them. 5/6 staff say charting and notes are being done but not on all shifts all the time and feel being shorthanded is the main reason why not all duties are completed by the end of shifts daily. Based on the evidence this allegation is deemed Substantiated at this time.
On the allegation: Staff did not meet the resident's hygiene and/or showering needs. LPA conducted interviews which revealed 5/6 staff, 5/8 witnesses and 2/6 residents stated in the memory care unit staff are shorthanded, showers are not getting completed as scheduled, Residents hair is left greasy and unwashed, residents are wearing clothing that does not belong to them and residents teeth are not being brushed. 5/6 staff stated that staffing is insufficient to get all residents services completed as scheduled, the residents are made to wait longer or refusing services due to staff running behind scheduled bathing/shower times. Based on the evidence this allegation is deemed Substantiated at this time.
On the allegation: Staff did not meet the resident's incontinence needs. LPA interviewed staff which revealed 5/6 staff stated the incontinent residents should be checked every 2 hours and due to staff being short handed the residents are waiting longer to be checked and some residents have had to wait in wet briefs. Based on the evidence this allegation is deemed Substantiated at this time.

Exit interview conducted, deficiencies cited, copy of report and appeal rights emailed to Administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20220721130540
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: 11/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/17/2022
Section Cited
CCR
87468.1(a)(8)
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(a)...(8)To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. This requirement was not met as evidence by:
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7
Administrator agreed to read, review and train staff that notify residents responsible parties in personal rights regulations 87468.1 and 87468.2. Have a clear written procedure of whom and
8
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13
14
Based on Interviews the Licensee did not comply with the regulation above 5/8 witnesses were not kept informed by the facility regarding resident’s care needs which is an immediate personal rights risk to residents in care.
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9
10
11
12
13
14
when to notify and the timeliness of these notifications as well as the documenting of these notifications. Provide proof of training and notification procedures to CCL
Type A
11/17/2022
Section Cited
CCR
87625(b)(3)
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5
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7
(b)...(3)Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met as evidenced by:
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7
Administrator agreed to read, review and train all staff that perform resident care in regulation 87625, have written procedure and a schedule of incontinent residents and a tracking system of
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Based on staff and witness interviews the Licensee did not comply with the regulation above residents were left wet for longer periods of time due to staffing shortages which posses an immediate health and safety risk to residents in care
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when and who has preformed the care. Provide proof of training, procedure and schedule to CCL.
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: 11/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 29-AS-20220721130540
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: 11/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/17/2022
Section Cited
CCR
87468.2(a)(4)
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2
3
4
5
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7
(a)...(4)To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Administrator agreed to hire more staff, provide training to all staff on personal rights 87468.1, 87468.2 and Basic services 87464, have written procedures and a schedule for staff to provide shower and
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14
Based on interviews the licensee did not comply with this regulation 5/6 witnesses 2/6 residents and 5/6 staff felt short staffing had led to missed showers and longer wait times, as well as some of the basic hygiene, teeth brushing, hair washing, and dressing is not being provided adequately to meet the residents needs which is an immediate personal rights risk to residents in care.
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9
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hygiene care. Provide proof of training, written procedure, shower schedules with columns to document refusals and completions.
Type B
11/24/2022
Section Cited
CCR
87506(b)(13)
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7
(b)...(13)Continuing record of any illness, injury, or medical or dental care, when it impacts the resident’s ability to function or needed services. This requirement was not met as evidenced by:
1
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3
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5
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7
Administrator agreed to read, review, and train all staff working with residents in regulation 87506, have clear written procedures of when and how to document residents, charts, files, and
8
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14
Based on 5/8 witness interviews the licensee did not comply with the regulation above records or documentation were not provided when requested which possess a potential health and safety risk to residents in care.
8
9
10
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13
14
records. Provide proof of training and written procedures to CCL
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: 11/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
07/21/2022 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20220721130540

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: 101DATE:
11/10/2022
UNANNOUNCEDTIME BEGAN:
05:25 PM
MET WITH:Tracy Flaherty, AdministratorTIME COMPLETED:
06:14 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Licensee did not ensure that changes in the resident were brought to the attention of physician in a timely manner.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above to deliver final findings of the investigation. LPA met with Tracy Flaherty, Administrator and explained the purpose of the visit.
LPA De Leon conducted the initial complaint visit on 01/26/2022. LPA conducted interviews with staff on 09/14/2022 around 4:00pm and on 11/07/2022 at 4:34pm, 5:29pm, 6:29pm, 6:51pm, and 7:15pm. LPA conducted interviews with residents on 11/02/2022 at 3:03pm, 11/04/2022 at 1:41pm, 1:47pm, 1:54pm, 4:30pm, and on 11/07/2022 at 4:02pm. LPA conducted interviews with witnesses on 11/02/2022 at 3:20pm, 4:00pm, 5:15pm, on 11/03/2022 at 5:27pm, on 11/04/2022 at 4:50pm, and on 11/07/2022 at 2:44pm, 3:29pm, and 3:48pm. LPA collected records on 01/26/2022, 07/26/2022, 09/14/2022 and 11/09/2022. LPA reviewed records on 10/31/2022, 11/02/2022, 11/03/2022, 11/04/2022 and 11/09/2022.
Unsubstantiated
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: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20220721130540
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
VISIT DATE: 11/10/2022
NARRATIVE
1
2
3
4
5
6
7
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12
13
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15
16
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32
On the allegation: Licensee did not ensure that changes in the resident were brought to the attention of physician in a timely manner. LPA interviewed Staff, Residents and Witnesses which did not reveal any known issues with residents’ doctors being notified about changes in residents. Based on the lack of evidence this allegation is deemed Unsubstantiated at this time.

Exit interview conducted and copy of report emailed to Administrator.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6