Oaks At Nipomo, The

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Facility doors are unsafe for residents in care. Staff are not following residents admission agreements.

Licensing Program Analyst (LPA) Melisa Rankin conducted an unannounced visit to initiate a complaint investigation regarding the above-mentioned allegations. LPA met with Ronald Freeman, to discuss the purpose of the visit and elements of the complaint. During the visit LPA collected staff schedules and observed and tested the function of external doors, interviewed 4 residents, 8 staff, a director and the administrator. LPA also toured restrooms, common areas, and a resident room. On the allegation: Staff are not following residents admission agreements. It was alleged that due to a lack of staffing the residents are not receiving weekly housekeeping and laundry services as stated in their admission agreements. Reporting party (RP) reported that residents are having to wash their own bedding when housekeeping is not available. Continued on 9099-C Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 1, 2025 · control 29-AS-20250924222649

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Facility failed to follow reporting requirements

Licensing Program Analyst (LPA) Rankin conducted a required 10-day complaint visit to the above facility. LPA met with Administrator Ron Freeman and explained the purpose of the visit. LPA was notified of possible outbreak on August 21st via correspondence with the Administrator. The administrator stated in correspondence that the county has also been contacted, and he was waiting for a response. During the complaint visit LPA interviewed the administrator, Memory care director, 10 staff, and 8 residents. LPA toured common area of the facility while speaking with staff and residents. Unsubstantiatedthe state’s words, verbatim · CDSS document, Sep 3, 2025 · control 29-AS-20250827080301

Allegation investigated: Licensee does not ensure that resident's are provided with an adequate supply of hygiene items while in care. Licensee does not ensure that resident is provided appropriate activities while in care.

Licensing Program Analyst (LPA) Rankin conducted a subsequent complaint visit to the facility above to issue final findings. LPA met with Ronald Freeman, Administrator and explained the purpose of the visit. During the initial visit on 6/23/25 from 10:55 am to 3:00 pm, LPA Rankin toured the memory care unit at the facility, interviewed two (2) staff, one (1) resident from Memory Care, and two (2) residents from Assisted Living, observed Memory Care residents and the activities, and obtained relevant documents. Additional interviews were conducted with relevant parties on 6/20/25, and 7/1/25. During return visit LPA re-toured the memory care unit and specifically 21 resident restrooms and two (2) staff/resident restrooms. LPA interviewed three (3) staff and one (1) director. (pg1) Continued 9099-C Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 2, 2025 · control 29-AS-20250619151313

Allegation investigated: Facility did not seek timely medical care for resident Facility did not meets resident's needs Facility did not provide adequate supervision Facility did not observe change of condition in resident Facility did not conduct reappraisal of resident

Licensing Program Analyst (LPA) Rankin conducted a subsequent complaint visit to issue final findings on this investigation. LPA met with Ronald Freeman and explained the purpose of the visit. During the investigation, LPA conducted an initial visit on 7/2/2024 from 2:14pm to 4:30pm where LPA conducted interview with administrator and obtained relevant documents. LPA conducted a visit on 5/29/25 from 12:11pm to 3:17pm, where LPA again interviewed administrator, and re-reviewed records. Additional staff interviews were conducted via phone on 5/30/25 at 1:09 to 1:52 p.m., in person on 6/23/25 at approximately 12:52pm to 1:10pm, and via phone on 6/26/25 at 10:24am to 10:32am and 12:19pm to 12:39pm. LPA attempted to call/interview nine staff listed on the staff roster who were staff in the memory care unit during the timeframe Resident 1 (R1) resided in the facility. Four of those staff were interviewed and the remaining five staff were contacted, but did not respond to requests for intervthe state’s words, verbatim · CDSS document, Jun 30, 2025 · control 29-AS-20240628143308

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Facility staff handle resident in a rough manner.

Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above. LPA met with Administrator Ronald Freeman and explained the purpose of the visit. LPA De Leon conducted the initial 10-day complaint visit, toured facility memory care unit, observed lunch service, requested records and interviewed staff at 10:45am, 11:00am, 12:40pm, 1:10pm, 1:20pm, 2:52pm and 3:11pm and interviewed residents at 11:20am, 11:45am, 2:00p and 2:20pm. LPA conducted a subsequnet complaint visit on 02/27/2025 and interviewed additonal staff from 10:45am-1:30pm. On the allegation: Facility staff handle resident in a rough manner. LPA De Leon interviewed staff, residents, and reviewed facility memory care records for staff and residents. Staff interviews revealed 1 out of 7 staff heard about an incident with a new NOC Caregiver Staff handling a resident roughly. Continued 9099-C Substantiatedthe state’s words, verbatim · CDSS document, Feb 27, 2025 · control 29-AS-20250203141805

Allegation investigated: Staff did not provide a proper eviction notice to resident in care

Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above. LPA met with Administrator Ronald Freeman and explained the purpose of the visit. LPA De Leon conducted the initial 10-day complaint visit, toured facility, requested records and interviewed staff at 10:45am, 11:00am, 12:40pm, 1:10pm, 1:20pm, 2:52pm and 3:11pm and interviewed residents at 11:20am, 11:45am, 2:00p and 2:20pm. LPA conducted a subsequent visit and interviewed staff and residents from 10:45am-1:30 pm. On then allegation: Staff did not provide a proper eviction to resident in care. LPA reviewed records regarding Resident 1’s (R1’s) eviction letter, Admission Agreement with Resident Handbook, and House Rules, and Letters to R1 from the facility, as well as interviewed staff and residents. Continued 9099-C Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 27, 2025 · control 29-AS-20250130150442

Allegation investigated: Staff handled resident in a rough manner Staff did not assist with medication as prescribed Staff did not address a resident's change in medical condition

Licensing Program Analyst (LPA) Erika Miller (Miller) conducted an unannounced complaint visit and issued final findings on the allegations above. During the investigation, LPA Miller, toured the facility and interviewed staff, and residents on October 22, 2024. LPA reviewed relevant documents. LPA met with Ronald Freeman, administrator and explained the purpose of the visit. On the allegation: Staff handled resident in a rough manner Reporting party (RP) alleges that they observed Resident 1 (R1), to be in severe pain and directed staff to stop their actions, (i.e.), stop changing R1’s brief. Continued on 9099-C Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 22, 2024 · control 29-AS-20240403105525

Allegation investigated: The facility apartments not being kept clean and free from odors. Facility staffing is not sufficient in dining to meet the needs of the residents

Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above to deliver final findings of the complaint investigation. LPA met with Ron Freeman, Administrator and explained the purpose of the visit. LPA De Leon conducted the initial complaint visit on 12/11/2023 toured the 2nd floor, requested records, conducted interview with staff at 11:05am, 11:30am, 11:45am, 12:00pm, 12:30pm, 12:45pm, 1:00pm and 1:30pm and residents at 2:52pm and 3:00pm. On the allegation: The facility apartments not being kept clean and free from odors. LPA conducted interviews with staff and residents which revealed a 2nd floor apartment had foul odors. On 04/29/2024 an incident report was provided to LPA Miller that R1 was transported to the hospital for mental health evaluation. Administrator stated R1 did not return to the facility after that date. Continued 9099-C Substantiatedthe state’s words, verbatim · CDSS document, Aug 28, 2024 · control 29-AS-20231204161250

Allegation investigated: Facility staff handles residents in a rough manner resulting in skin tears. Facility staff using profanity towards residents. Facility staff does not wear gloves when preparing food.

Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above to deliver final findings in the complaint investigation. LPA met with Ronald Freeman Administrator and explained the purpose of the visit. LPA De Leon conducted the initial investigation on 01/20/2023, LPA toured the kitchen with Administrator, LPA collected the following records: Resident Roster with telephone numbers, Staff Roster with Telephone numbers, Staff schedule for January 2023 for Kitchen staff, caregivers and med-tech's, Kitchen menu, Kitchen cleaning checklist, Any disciplinary records for staff 1 (S1) or any other staff using profanity, any incident reports of Residents with food poisoning, Any resident evictions for January 2023, and Infection Control Training Records for all staff, LPA interviewed staff at 1:19pm, 2:02pm, 2:20pm, 2:45pm, and 3:20pm. Continued 9099-C Substantiatedthe state’s words, verbatim · CDSS document, Aug 27, 2024 · control 29-AS-20230119132542

Allegation investigated: Facility refused to provide transportation for the resident's appointment.

Licensing Program Analyst (LPA) Rankin conducted a subsequent complaint visit to the facility above to issue final findings. LPA met with Ronald Freeman and explained the purpose of the visit. During the investigation, LPA Rankin conducted an initial visit on 8/19/24 from 10:58am to 2:15pm, toured the common areas of the facility, interviewed staff, interviewed residents, and obtained documents. LPA conducted additional interview with resident 1 (R1) on 8/23/2023 at 9:05 am. Continued to 9099-C Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 23, 2024 · control 29-AS-20240813082147

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff do not assist residents with showering. Staff do not answer residents' pendants in a timely manner.

Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above to deliver final findings of the complaint investigation. LPA met Raquel Counsins, Memory Care Director with and explained the purpose of the visit. LPA De Leon conducted the initial 10-day visit on 12/13/2022 at 9:30am, LPA conducted staff interviews at 10:30am, 12:30pm, 1:10pm, 2:30pm, and collected records requested. On 08/23/2023 LPA De Leon conducted a subsequent visit to the facility interviewed staff at 10:15am, 11:10am, 11:50am, 12:05pm, 1:05pm, 1:20pm, 1:40pm, 2:20pm, 3:30pm, 4:15pm and interviewed residents at 12:15pm, 12:30pm, 12:45pm, 2:55pm, On 08/24/2023 collected records, conducted interviews with staff 11:18am, with residents at 12:20pm, 12:40pm, 1:45pm, 2:12pm, 3:15pm, 5:00pm and 5:37pm. Continued 9099-C Substantiatedthe state’s words, verbatim · CDSS document, Jun 19, 2024 · control 29-AS-20221205120051

Allegation investigated: Staff did not discard contaminated food.

Licensing Program Analyst (LPA) Erika Miller (Miller) conducted an unannounced complaint visit and issued final findings on the allegations above. During the investigation, LPA, Miller, toured the Memory Care Unit and interviewed staff, and residents on February 8, 2024, from 1:39 p.m. to 3:15 p.m. LPA also obtained and reviewed relevant documents. LPA met with Ronald Freeman, administrator and explained the purpose of the visit. On the allegation: Staff did not discard Contaminated food. On February 5, 2024, a witness visited the facility, and observed open containers of food in the small fridge in the pantry area, including a container with mold growing on it. See photograph of moldy juice box. The memory care director stated that staff is instructed to check the refrigerator on a daily basis. In addition, the NOC shift in memory care is required to go through the refrigerator and check for expired foods once a week as outlined in the NOC Caregiver Duties check list. In the event, fothe state’s words, verbatim · CDSS document, Feb 8, 2024 · control 29-AS-20240206161459

Allegation investigated: Facility does not provide adequate amounts of toilet paper to residents in care.

Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above to deliver final findings of the complaint investigation. LPA met with the Administrator Ron Freeman and explained the purpose of the visit. LPA De Leon conducted the initial complaint visit on 08/23/2023, LPA requested staff roster with telephone numbers, resident roster, invoices for billing of toilet paper for 2022-2023, staff schedule for August 2023 all departments. The administrator provided all the above except the invoices for toilet paper as none of the residents have been billed for toilet paper. The facility does provide housekeeping 1 day a week in each resident’s room and the housekeepers are instructed to put toilet paper if the resident’s bathroom if it does not have any. The Admission Agreement was reviewed, and it does not state the facility provides toilet paper free of charge and it does not state toilet paper is an extra charge. LPA interviewed staff on 08/23/2023 arthe state’s words, verbatim · CDSS document, Sep 15, 2023 · control 29-AS-20230816143650