Oaks At Paso Robles, 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.

Allegation investigated: Staff do not ensure resident is provided clean linens Staff do not ensure resident is provided assistance with personal grooming and dressing

On 10/1/2025 at 1:00pm Licensing Program Analyst (LPA) Haner-Tomasko arrived unannounced at the facility to deliver final findings to this complaint. LPA met with Administrator Carl Meyer and explained the purpose of the visit. On 07/08/2025, Licensing Program Analyst (LPA) Haner-Tomasko conducted an unannounced initial complaint investigation visit to the facility. During the visit, the LPA requested and received facility documentation relevant to the investigation. LPA interviewed residents, staff, and the Administrator. The LPA determined further investigation was needed prior to issuing findings. On allegations: Staff do not ensure resident is provided clean linens and staff do not ensure resident is provided assistance with personal grooming and dressing. It was alleged that Person #1 (P1) found Resident #1 (R1) left in soiled bed sheets one day in June 2025 and R1’s hair was not brushed. (Conintued on 9099-C) Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 1, 2025 · control 29-AS-20250630114830

Allegation investigated: Due to lack of supervision, resident has fallen multiple times resulting in injuries

On 10/1/2025 at 1:00pm Licensing Program Analyst (LPA) Haner-Tomasko arrived unannounced at the facility to conduct a subsequent complaint visit to deliver findings for the above allegation. LPA met with Administrator Carl Meyer and explained the purpose of the visit. On 03/13/2025, the Woodland Hills North Adult and Senior Care Regional Office (RO) originally received this complaint regarding neglect/lack of care and supervision. The complaint alleged that Resident #1 (R1) sustained multiple falls and injuries while in care at the facility due to staff neglect and lack of supervision. The complaint also included an allegation that food is not of quantity to meet the needs of residents. On 3/18/2025 the complaint was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Jorge Jauregui. (Continued on LIC9099-C) Substantiatedthe state’s words, verbatim · CDSS document, Oct 1, 2025 · control 29-AS-20250313093906

Allegation investigated: Due to neglect, Resident sustained multiple UTIs while in care. Facility is not clean/sanitary. Facility does not have adequate amount of staff to attend to residents.

On 10/1/2025 at 1:00pm Licensing Program Analyst (LPA) Haner-Tomasko arrived unannounced at the facility to deliver final findings to this complaint. LPA met with Administrator Carl Meyer and explained the purpose of the visit. On 03/18/2025, the Woodland Hills North Adult and Senior Care Regional Office (RO) originally received this complaint regarding neglect/lack of care and supervision. The complaint alleged that Resident #1 (R1) sustained multiple urinary tract infections (UTIs) while in care at the facility due to staff neglect and lack of supervision. The complaint also included an allegation that the facility is not clean/sanitary. On 3/13/2025 the RO received a similar complaint with control number 29-AS-20250313093906 was also regarding R1 sustaining multiple falls due to neglect/lack of care and supervision. That complaint was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Jorge Jauregui. Investigator Jaurequithe state’s words, verbatim · CDSS document, Oct 1, 2025 · control 29-AS-20250318102817

Allegation investigated: Staff handled residents in a rough manner Staff yelled at residents

On 9/4/2025 at 10:00am Licensing Program Analyst (LPA) Haner-Tomasko arrived unannounced at the facility to investigate the allegations to this complaint. LPA met with Administrator Carl Meyer and explained the purpose of the visit. During the visit, LPA interviewed staff, residents, the Administrator, and obtained relevant documents. On allegations, staff handled residents in a rough manner and staff yelled at residents. It was alleged Staff #1 (S1) forcefully pulls and grabs residents from their wheelchairs, chair, and bed. It was alleged that S1 yells at the residents, telling them they have to wait even though they have already waited a while. Other staff have witnessed S1 yelling at residents. Resident interviews revealed there are times S1 seems rushed to help residents depending on staffing and (Continued on LIC9099-C) Unsubstantiatedthe state’s words, verbatim · CDSS document, Sep 4, 2025 · control 29-AS-20250827135624

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: Resident sustained multiple pressure injuries while in care due to staff neglect Resident sustained unexplained injuries while in care Resident's toileting needs are not being met

On 8/27/2025 at 10:30am Licensing Program Analyst (LPA) Haner-Tomasko arrived unannounced at the facility to further investigate the allegations to this complaint. LPA met with Administrator Carl Meyer and explained the purpose of the visit. During the visit LPA interviewed staff, administrator, and obtained relevant documents. On the allegations: Resident sustained multiple pressure injuries while in care due to staff neglect and resident sustained unexplained injuries while in care. It was alleged Resident 1 (R1) had approximately 4 wounds or pressure injuries about the size of a quarter or half-dollar and what appeared to be bruising on their tailbone and back. (Conitnued on LIC9099-C) Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 27, 2025 · control 29-AS-20250403134447

Allegation investigated: Staff do not ensure toilet paper is in resident bathroom Staff do not ensure residents have soap in bathroom

On 8/27/2025 at 10:30am Licensing Program Analyst (LPA) Haner-Tomasko arrived unannounced at the facility to further investigate the allegations to this complaint. LPA met with Administrator Carl Meyer and explained the purpose of the visit. During the visit, LPA interviewed staff, administrator, and obtained relevant documents. On allegation: Staff do not ensure toilet paper is in resident bathroom and staff do not ensure residents have soap in bathroom. It was alleged Resident #1 (R1) had no toilet paper on multiple occasions and resident families must provide toilet paper. On one occasion R1 had no toilet paper in their bathroom and their personal supply of toilet paper was locked up. R1 is not able to make needs known to staff, unable to ask staff to get their toilet paper. (Continued on LIC9099-C) Substantiatedthe state’s words, verbatim · CDSS document, Aug 27, 2025 · control 29-AS-20250521121107

Allegation investigated: Staff did not treat resident with dignity.

On 07/23/2025 at 10:14am Licensing Program Analyst (LPA) Haner-Tomasko arrived unannounced at the facility to investigate the allegation to this complaint. LPA met with Administrator Carl Meyer and explained the purpose of the visit. On allegation: Staff did not treat resident with dignity. It was alleged the facility Executive Director Carl Meyer did not treat Resident #1 (R1) with dignity and has referred to the resident in a derogatory way when speaking to staff. LPA interview with R1 revealed they recently had an issue they brought to Carl's attention and R1 stated they were happy with how Carl resolved the issue. LPA staff interviews revealed that staff are not aware of any facility staff treating residents in an undignified way or referring to residents in a derogatory way. LPA interview with Administrator Carl Meyer, revealed he followed up with R1 on their issue and needed provide R1 with reminders on house rules. (Continued on LIC9099-C) Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 23, 2025 · control 29-AS-20250718110005

Allegation investigated: Staff not providing assistance to resident in a timely manner. Residents are not being provided clean linens. Staff does not keep facility free from odor.

On 07/23/2025 at 10:14am Licensing Program Analyst (LPA) Haner-Tomasko arrived unannounced at the facility to continue the investigation on the allegations to this complaint. LPA met with Administrator Carl Meyer and explained the purpose of the visit. During the visit, from 10:40am to 4:00pm LPA interviewed residents, staff, administrator, and obtained relevant documents. On allegation: Staff not providing assistance to resident in a timely manner. It was alleged that residents have to wait for long periods of time to receive assistance. LPA interviews with staff and Administrator Carl Meyer revealed that staff are expected to respond to resident calls for assistance within 10 minutes. (Conitnued on LIC 9099-C) Substantiatedthe state’s words, verbatim · CDSS document, Jul 23, 2025 · control 29-AS-20250506110349

Allegation investigated: Staff is not allowing resident a visitor

On 07/17/2025 at 3:00pm Licensing Program Analyst (LPA) Haner-Tomasko arrived unannounced at the facility to investigate the allegation to this complaint. LPA met with Executive Director/Administrator Carl Meyer and explained the purpose of the visit. During previous visits to the facility, the LPA interviewed staff, clients, licensee, and obtained relevant documents. On the allegations: Staff is not allowing resident a visitor. It was alleged the facility did not allow a hospice volunteer to visit a resident currently on service with the hospice agency. The volunteer, Person #1 (P1), is a former employee of the Oaks at Paso Robles. (Continued on LIC809-C) Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 17, 2025 · control 29-AS-20250505084727

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 did not administer residents’ medication.

At 9:00am on 02/27/2025, Licensing Program Analyst (LPA) Jeffries and Haner-Tomasko arrived to the facility unannounced to issue final findings on the allegation to this complaint. LPA's met with Administrator Carl Meyer, announced who they are and the reason for the visit. LPA's also conducted facility annual for 2025 and issued final findings on two other different complaints on this visit. As to the allegation of, “Staff did not administer residents’ medication.” It was alleged that Resident 1 (R1) was paying for medication management that was not being conducted correctly during the time period of July 2023 through October of 2024 (approximately 398 days). It was discovered through interviews, observations, medication audit, and physical medication count; that on 01/22/2025, Licensing Program Analyst Jeffries (LPA) conducted a phone interview with Family Member 1 (F1). F1 stated that the facility had returned 5 different types of medication to F1 after R1 was no longer a resident othe state’s words, verbatim · CDSS document, Feb 27, 2025 · control 29-AS-20250122091828

Allegation investigated: Facility staff did not dispense medications according to physician's orders. Facility staff did not ensure residents had drinking water. Facility staff did not meet resident's incontinence care needs.

At 9:00am on 02/27/2025, Licensing Program Analyst (LPA) Jeffries and Haner-Tomasko arrived to the facility unannounced to issue final findings on the allegations to this complaint. LPA's met with Administrator Carl Meyer, announced who they are and the reason for the visit. LPA's also conducted facility annual for 2025 and issued final findings on two other different complaints on this visit. As to the allegation of, “Facility staff did not dispense medications according to physician's orders.” It was alleged that on 08/08/2024 and 08/09/2024 that Staff 6 (S6) administered the residents' 4pm medications and 6pm medications at the same time and not according to physicians’ orders in memory care unit. It was discovered through interviews and documentation that on 08/19/2024, LPA Jeffries attempted to interview residents 1-5 (R1, R2, R2, R4, and R5), basic screening question did result in cognitive normal answers or silence. On 08/19/2024, LPA Jeffries conducted an interview with S1 whothe state’s words, verbatim · CDSS document, Feb 27, 2025 · control 29-AS-20240815101438

Allegation investigated: Staff do not ensure that the facility is maintained sanitary.

At 9:00am on 02/27/2025, Licensing Program Analyst (LPA) Jeffries and Haner-Tomasko arrived to the facility unannounced to issue final findings on the allegations to this complaint. LPA's met with Administrator Carl Meyer, announced who they are and the reason for the visit. LPA's also conducted facility annual for 2025 and issued final findings on two other different complaints on this visit. As to the allegation of, “Staff do not ensure that the facility is maintained sanitary.” It was alleged that “the facility and residents' rooms smells like poop because of the residents urinating and defecating everywhere.” It was discovered through observation, interview and documentation that on 05/23/2024 in a facility physical inspection with Facility Administrator Carl Meyer and LPA Jeffries, observed R1’s room had an overwhelming smell of ammonia, and trace evidence if fecal matter on the floor. LPA noted that there was an attempt to clean the room however that the ammonia and urine smell wthe state’s words, verbatim · CDSS document, Feb 27, 2025 · control 29-AS-20240522102559

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: Resident sustained pressure injuries while in care. Facility staff is not maintaining proper fire safety precautions at the facility. Residents are not provided proper food service. Staff do not order resident's medication in a timely manner. Staff did not assist resident with their doctor's appointment.

At 8:00am on 06/10/2024, Licensing Program Analyst (LPA) Jeffries arrived to the facility unannounced to delivering final findings to the allegations to this complaint, as well as a second complaint, and a complaint visit on a thrid complaint. LPA met with facility Administrator, Carl Meyer, announce who he is and the reason for the visit. As to the allegation of, “Resident sustained pressure injury while in care.” It was alleged that resident was neglected and obtained bed sores. It was discovered through documentation and interviews that on 01/17/2023, LPA Jeffries reviewed all R13 medical files and documentation and discovered a facility Health and Service Evaluation report indicated that they were tracking “current or historical skin condition” (nothings specific specified) dated 10/16/2022. On 12/01/2022 Resident 13 (R13) had been diagnosed with COVID, documented on LIC624(Unusual Incident/Injury Report), with notification to R13’s Physician, Responsible Party, and submitted to Cothe state’s words, verbatim · CDSS document, Jun 10, 2024 · control 29-AS-20221228105128

Allegation investigated: Facility staff yell at residents. Facility staff inappropriately handled resident in a rough manner. Facility staff do not adequately supervise residents. Facility staff do not treat residents with dignity and respect.

At 8:30am on 06/10/2024, Licensing Program Analyst (LPA) Jeffries arrived to the facility unannounced to delivering final findings to the allegations to this complaint, as well as a second complaint, and a complaint visit on a thrid complaint. LPA met with facility Administrator, Carl Meyer, announce who he is and the reason for the visit. As to the allegations, “Facility staff yell at residents.” It was alleged that a caregiver Staff 7 (S7) yelled at residents. It was discovered through documentation, and interviews that, On 01/12/2023 interviews of S1-S6 all stated that they had never heard S7 raise their voice or yell at residents. In interviews with R1 – R16 on 01/12/2023, all residents denied any staff ever yelling or raising their voice with residents. LPA reviewed facility only termination notice during this time frame (January 2023 – March 2023) and there was only one termination of staff due to an unrelated contractual conflict. At this time there is not enough evidence to supthe state’s words, verbatim · CDSS document, Jun 10, 2024 · control 29-AS-20230106094616

Allegation investigated: Staff failed to observe resident’s nail care needs.

On 05/23/2024, at 8:30am, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to issue final findings to the allegation to this complaint. LPA also issue final findings on additional complaint and conducted initial investigation visit on a third complaint on this visit. LPA met with Administrator, Carl Meyer, announced who he is and the reason for the visit. As to the allegation of, “Staff failed to observe resident’s nail care needs.” It was alleged that two residents were neglected to the point of having nail fugus. It was discovered through interviews, documentation and observation that on 03/23/2023, LPA conducted interview with Administrator, Administrator stated that the Podiatrist, Dr. Tisngson, DPM was at this facility today (03/23/2023) and was scheduled to treat two residents (R1 and R2). Administrator stated that R1 had a visit with the Podiatrist and R2 refused Podiatrist treatment on this visit. Administrator stated the Podiatrist routinely visit tthe state’s words, verbatim · CDSS document, May 22, 2024 · control 29-AS-20230320095114

Allegation investigated: Staff allow resident to continue self-neglect.

On 05/23/2024, at 8:30am, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to issue final findings to the allegation to this complaint. LPA also issue final findings on additional complaint and conducted initial investigation visit on a third complaint on this visit. LPA met with Administrator, Carl Meyer, announced who he is and the reason for the visit. As to the allegation of, “Staff failed to observe resident’s continued self-neglect.” It was alleged that, Resident (R1) smells of urine and is generally observed to be wet with urine.” It was discovered through interviews, observations, and documentation, that on 01/26/2023, LPA conducted an in-room interview with resident 1 (R1). R1 stated that they did have an incontinence problem and stated it was due to, “not being able to move as fast as (they) use to.” R1 stated that staff is always there to help, however R1 also stated, “I am still independent and use their (staff) help when I need to.” R1 stated ththe state’s words, verbatim · CDSS document, May 22, 2024 · control 29-AS-20230124131216

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 are denying resident indoor visitations. Staff are not following resident's care plan. Staff are not turning resident sufficiently.

At 10:00am on 08/22/2023, Licensing Program Analyst (LPA) Jeffries arrived unannounced at the facility to issue final findings to the allegations above. LPA met with Administrator Carl Meyer, announced who he was and the reason for the visit. As to the allegation of, “Staff are denying resident indoor visitations.” It was discovered through interviews and documentation that, on 10/17/2022 at 3:03pm, the initial contact phone call with F1, it was discovered that F1 and facilities prior administrator (Ron Freeman) had made an agreement to circumvent COVID-19 screening protocols which were enforced during the time this complaint was submitted, which was address on a subsequent complaint (29-AS-20220615114827). Interviews on 10/21/2022 with S1-4 indicated that Mr. Freeman had knowledge and/or provided consent for F1 utilizing the first-floor exit door to enter the facility without screening for COVID-19 symptoms. CONTINUED on LIC9099-C Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 22, 2023 · control 29-AS-20221017114617