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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405809547
Report Date: 07/14/2023
Date Signed: 07/14/2023 04:17:32 PM


Document Has Been Signed on 07/14/2023 04:17 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



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: DATE:
07/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Ronald Freeman, AdministratorTIME COMPLETED:
04:25 PM
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Licensing Program Analyst (LPA) De Leon arrived at 11:45 am to conducted a 1 year annual visit to the facility above. LPA met Administrator Ronald Freeman and explained the purpose of the visit.

A tour of the inside and outside of the facility was conducted with Administrator. The following was inspected and noted during the annual visit:

Infection Control: The facility has submitted a current Mitigation Plan and Infection Control Plan. The facility has a sign in and out binder for visitors at entry with hand sanitizer and symptom screening. The bathrooms have toilet paper, paper towels, hand soap, and hand washing signs. The facility has EPA approved disinfectants spray and cleaners.

Physical Plant & Environment Safety: The facility has 97 bedrooms and 97 bathrooms and 8 public restrooms currently occupying 101 residents and employs 68 staff. The facilities common areas were clean, safe and sanitary. Memory Care is called Compass Rose with 30 residents living in the locked coded entry and delayed egress on exiting doors. LPA was authorized to enter and inspect facility. The lighting and lamps are sufficient for the use of the facility and for residents comfort. The facilities main kitchen is clean, safe and sanitary. The memory care kitchen needed cleaning of the floors, stove, oven, cupboards, microwave and outside of the refrigerator. Rooms 1A, 1B and 13 were toured in Compass Rose, rooms were clean and comfortable for residents use, bathrooms were clean, showers have non-skid textured floors, and grab bars were secured. Toilet, hand washing and bathing facilities were operational. The pathways were clear of any obstructions. Fire place has a screened covering. Disinfectant, cleaning solutions and poisons are inaccessible to residents in care. The facility has sufficient space inside and outside for activities and visiting. The facility has a two enclosed courtyards one for Assisted living resident and one for Memory Care residents with plenty of shade for resident use. The facility has telephone and internet service for all residents in care.

Operational Requirements: The facility has a current plan of operation and infection control plan on file with the department. The facility is approved for a capacity of 122 Non-Ambulatory, which 12 may be bedridden and a current Hospice wavier is granted for 12. The Facility is operating in compliance with the granted fire clearance.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2023
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 17


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/14/2023
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Staffing: The facility employes 67 staff and 1 Administrator. Staff records are kept confidential. LPA will return at a later date to review staff files.
Personnel Records & Training: The facility keeps confidential files locked for each staff member. LPA will return at a later date to review staff training records.
Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. LPA will return at a later date to review residents records and files. Facility does submit incident reports to the department when required.
Resident Rights Information: All require postings were posted in the common area of the facility. Personal rights, Rights to Resident Council, and Theft and Loss policy. CCL Complaint poster was 20x26 in size and had been moved from the prior locations on LPA's last visit, Administrator agreed to have Assisted Living and Memory Care posters moved back into the entryways of the facility. The LTCO poster was posted in the common area hallway of the facility. The current license was posted at entry.
Planned Activities: The facility offers activities to all residents in care. The facility employs an Activities Director and a monthly calendar with all activities is posted. The facility also offers additional activities to include books, magazines, newspapers, television, daily walks, group discussions and communications, games and puzzles. The facility has sufficient space to allow for activities indoors and outdoors as well as an activity room. LPA observed Bingo being played in the dining room for assisted living residents and Bingo was being played in the activities room in Compass Rose Memory care.
Food Service: The facility employs food service staff. The facility handles and prepares food safely. The facility has 2 day perishables and 7 day non-perishables to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower. All food was covered, stored and marked appropriately in the main kitchen. The Compass Rose kitchen did have some food left out and not covered as well as food stored in the refrigerator without being covered. Food, snacks and drinks are available when the residents want them. A menu is posted for residents in care. Cleaning solutions and equipment were stored separately than food supply. Main Kitchen areas were clean and free from litter, rodents, vermin and insects. Kitchen staff were observed for personal hygiene and food sanitation practices.
Incidental Medical & Dental: Facility provides transportation to medical and dental appointments when needed. LPA will return to review medication records at a later date.
Disaster Preparedness: The current emergency disaster form revised 03/2019 was not posted. The old form was but it does not include all the required information as it does on the new revised form. Staff person did print new form and was updating it on LPA's visit. The fire extinguishers were charged and last inspected on 09/13/2022. Emergency exits and telephone numbers were posted.
Residents with Special Health Needs: The facility does accept dementia residents in care. All items that could pose a danger, sharps, cleaners were locked or in accessible to residents in care. The facility does have delayed egress in Compass Rose Memory Care exiting doors as well as a key coded entry and exiting door. The facility does have residents with oxygen and required signs are posted on residents doors.

LPA will return at a later date to complete the annual.
Exit interview conducted and copy of report printed for Administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023
LIC809 (FAS) - (06/04)
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