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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405850480
Report Date: 07/09/2026
Date Signed: 07/09/2026 01:59:56 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
03/11/2026 and conducted by Evaluator Garrett Haner-Tomasko
COMPLAINT CONTROL NUMBER: 29-AS-20260311171250
FACILITY NAME:OAKS AT PASO ROBLES, THEFACILITY NUMBER:
405850480
ADMINISTRATOR:ROBIN MURRAYFACILITY TYPE:
740
ADDRESS:526 S RIVER ROADTELEPHONE:
(805) 239-5851
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY:120CENSUS: 90DATE:
07/09/2026
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator - Robin MurrayTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff caused injury to resident in care.
Staff handled resident in a rough manner while in care.
Staff did not follow reporting protocols as necessary.
INVESTIGATION FINDINGS:
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At 10:00am, on 7/9/2026, Licensing Program Analyst (LPA) Haner-Tomasko arrived at the facility unannounced to further investigate and deliver final findings of the above allegations. LPA met with Administrator Robin Murray, announced who he was and the reason for the visit.

During a visit on 3/18/2026, LPA conducted interviews and collected relevant documentation.

On the allegation: staff did not follow reporting protocols as necessary; it was alleged that Resident #1 (R1) was injured by staff during personal care causing R1 to have a raised swollen bruise on their chest approximately three inches long by two inches wide. It was also alleged that R1 reported this incident to Staff #1 (S1) moments after it occurred and on 2/18/2026, R1 told a witness (W1). W1 brought this information to the Administrator’s attention on the same day, 2/18/2026. It was alleged the facility did not report the suspected physical abuse of R1 as required within 24 hours to the proper agencies.
(Continued on LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Garrett Haner-Tomasko
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2026
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 5
Control Number 29-AS-20260311171250
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 PASO ROBLES, THE
FACILITY NUMBER: 405850480
VISIT DATE: 07/09/2026
NARRATIVE
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Interviews revealed that R1 did have an injury matching the description as alleged and that the injury showed up on approximately 2/17/2026. On 2/18/2026, the Administrator was made aware of R1’s injury by W1 and that the suspected cause was physical abuse from staff. W1 reminded the Administrator of the requirement to report this incident within twenty-four (24) hours to the proper agencies. Record review and additional interviews revealed that the facility submitted an incident report (LIC624) to Community Care Licensing Division (CCLD) on 2/24/2026, indicating R1 had a discoloration on their sternum that they stated was received from care staff and that R1 had also reported it to a med-tech days prior stating they had received it in the shower. The facility reported the suspected physical abuse of R1 to the Local Ombudsman office on 2/25/2026 via a written Report of Suspected Dependent Adult/Elder Abuse form (SOC341). Record review and interviews reveal the facility never reported it to local law enforcement. CCLD cross reported the alleged abuse to law enforcement. Interviews with the Administrator, Memory Care Director, and Regional Nurse revealed differing explanations for why the incident was not reported within the required time frame of two (2) hours verbally to law enforcement and twenty-four (24) hours in writing using form SOC341 to the long-term care ombudsman, law enforcement and CCLD. Despite these differing perspectives, all three individuals are mandated reporters and had sufficient information to ensure timely reporting. The delay therefore reflects a collective failure to fulfill mandated reporting obligations. The facility has since changed their reporting protocol to ensure reports are sent timely.

Based on all interviews conducted and documents obtained, the facility did not follow reporting protocols by taking over twenty-four (24) hours to report suspected elder abuse and never reported it to local law enforcement as required by law, at this time the above allegation was found to be substantiated, there is a preponderance of the evidence to prove that the alleged violation occurred.



On the allegations: staff caused injury to resident in care and staff handled resident in a rough manner while in care; it was alleged that Resident #1 (R1) was injured by three staff pulling and tugging on R1 while they assisted R1 with a shower on a day in February 2026 resulting in a raised swollen bruise on R1’s chest approximately three inches long by two inches wide. R1’s right arm also hurt due to the incident.

(Continued on LIC9099-C)

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Garrett Haner-Tomasko
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20260311171250
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 PASO ROBLES, THE
FACILITY NUMBER: 405850480
VISIT DATE: 07/09/2026
NARRATIVE
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While investigating this complaint the facility self-reported two additional incidents regarding staff handling residents in a rough manner. On 3/24/2026 CCLD received an incident report and SOC341 from the facility regarding another resident, Resident #2 (R2), who had a discolored spot and small skin tear on their right hand. Interviews revealed the discolored spot and skin tear occurred during care of the resident when staff grabbed and pulled on R2’s hand while they were turning R2 in bed. On 6/25/2026 LPA received a phone call from the Administrator and an SOC341 on 6/26/2026 regarding an incident that occurred on 6/24/2026 where multiple witnesses observed Staff #2 (S2) hold Resident #3’s (R3’s) hands down so that R3 could not move their arms and then S2 wrapped their arms around R3 and roughly transfered R3 to a wheelchair causing R3 to raise their voice stating “that hurt”. Staff assessed R3 for visible injury. S2’s employment was terminated on 6/25/2026.

Based on all interviews conducted and record review, staff handled R1, R2, and R3 in a rough manner resulting in pain and/or injury, at this time the above allegations was found to be substantiated, there is a preponderance of the evidence to prove that the alleged violations occurred.



Exit interview conducted, deficiencies cited on LIC9099-D page, report signed, appeal rights and report provided to the Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Garrett Haner-Tomasko
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20260311171250
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 PASO ROBLES, THE
FACILITY NUMBER: 405850480
VISIT DATE: 07/09/2026
NARRATIVE
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LPA record review revealed R1’s medical assessment dated 10/12/2025 states R1 is not able to bathe self and is diagnosed with dementia. R1’s service plan dated 11/13/2026 states under “Bathing” that R1 requires stand-by assist when bathing, it also states R1 requires moderate/max assist with bathing, 1 person assist. A note in R1’s digital chart created at 4:19am on 2/17/2026 states that R1 made the medication technician (med-tech) aware of a bruise on R1’s chest, the bruise is 1.5-inch x 3-inches on R1’s breast bone, and the resident told the med-tech that it was from a shower done the day before. The facility shower schedule indicates R1 is scheduled showers three days a week including Mondays, and 2/16/2026 was a Monday. Staff stated that R1 did have a shower that Monday, 2/16/2026. Staff interviews revealed R1 needs assistance from two to three staff during showers because R1 does not like taking showers or getting their hair wet. Staff and resident interviews revealed that R1 did have an injury matching the description as alleged, that the injury showed up on approximately 2/17/2026, and appeared as discolored skin on R1’s chest; some interviews stated it looked like a bruise. Interviews and record review revealed, though diagnosed with dementia, R1 on multiple occasions consistently described to different people the circumstances, number of staff involved and approximate date of the injury. On 2/18/2026, R1 stated to W1 there were 3 staff tugging and pulling on them in the shower when they refused to have their hair washed, this happened during their last shower and R1 reported this to S1; on the same day, R1 stated to W1 and the facility Administrator that the injury occurred when staff were being rough with them while assisting with their shower and R1 told S1 about it; on 3/13/2026, R1 stated to law enforcement that the injury occurred approximately a month ago when three staff entered their room, grabbed their arms forcing them to take a shower, they told the staff they did not want to shower because they had just had their hair done, and after the staff left R1 reported the incident to S1; and on 3/18/2026 R1 stated to the LPA that three or four weeks ago, three staff forced them to take a shower, during the shower R1 received an injury to their chest, and that they reported it to S1 who does not work at the facility anymore. Additional interviews confirm S1 no longer works at the facility for unrelated reasons and S1 was unable to be interviewed.

(Continued on LIC9099-C)

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Garrett Haner-Tomasko
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20260311171250
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 PASO ROBLES, THE
FACILITY NUMBER: 405850480
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/09/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/10/2026
Section Cited
CCR
87468.1(a)(1)
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(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by:
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Facility terminated S2's employment and provided other staff corrective action. Administrator states they will conduct staff training during the next all staff on 7/21/2026 regarding dignity and handling of residents and email LPA the training notes and staff roster by 7/23/2026
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Based on record review the Licensee did not comply with the regulation above, when staff handled R1, R2 and R3 in a rough manner resulting in injury which is an immediate health, safety, and personal rights risk to residents in care.
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Type B
07/23/2026
Section Cited
CCR
87211(c)
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(c) Any suspected physical abuse that does not result in serious bodily injury of an elder... adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours...
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The facility has changed the reporting protocol. The Administrator states they conducted mandated reporter training on 6/16/2026 at the all staff meeting and will emial the LPA the training notes and roster from that training by 7/23/2026.
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This requirement was not met as evidenced by: Based on interview and record review, the Licensee did not ensure suspected physical abuse of R1 was reported as required which poses a potential health, safety, and personal rights risk to persons 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 Burley
LICENSING EVALUATOR NAME: Garrett Haner-Tomasko
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5