complaint·October 1, 2025

LPA reviewed admission agreement which states under section (h.) “The Oaks at Nipomo will provide routine weekly housekeeping services to your Apartment, including laundering sheets and towels.” Interviews and records confirm the time frame for this concern started after 9/11/25. The facility employs four housekeepers. However, for a brief period, two housekeepers were unavailable due to valid personal reasons, one on extended medical leave and one due to an life-threatening emergency. Staff interviews indicated that while no temporary staff were hired due to State Licensing guidelines which delay background checks, overtime was offered to existing staff to help maintain services, including staff in other departments. The administrator confirmed that staff from other departments assisted with housekeeping duties during this time but declined the overtime to fully cover open shifts. The facility has hired another housekeeper who is currently going through the required background checks. During interviews, report that routine housekeeping services were missed during the dates of 9/24/25 and 9/25/25, but the services were provided within 3 days of their routine date, and any resident needing services sooner were provided support within 24 hours. Residents interviewed did not state they were impacted by this temporary schedule, they have not heard of others stating they have any issues. There is no indication that the issue is ongoing or systemic. The facility made reasonable efforts to mitigate the impact of the staffing shortage, and there is no evidence that the facility willfully failed to uphold the admission agreement. Although there was a brief disruption in routine housekeeping services due to an unforeseen staffing emergency, the facility took reasonable steps to address the issue. The evidence does not support a finding that the facility failed to follow the admission agreement in a manner that was systemic or intentional. Therefore, based on interviews, records reviewed and observation, the allegation is deemed to be Unsubstantiated at this time. On the allegation: Facility doors are unsafe for residents in care. It was alleged that the doors from the dining room to the patio door are difficult for the residents that use wheelchairs or walkers to open in either direction. RP also reported that several people have been hurt trying to get through the doors and that one resident almost fell going through the door last week. RP also reported that the residents have requested handicap accessible doors. RP also reported that residents have brought the issue to the administrator's attention repeatedly and have been told that the doors will not be changed. Continued on 9099-C During resident and staff interviews the LPA found no confirmation that the doors have caused injury to any residents in care. On 9/30/25 LPA reviewed internal incident reports and incident reports provided to licensing for dates of 1/2/25 to 7/2/25 provided for another complaint and found that no reports of falls or injuries were due to the patio doors or any other external doors, total number of reports reviewed was 135. LPA tested both sets of doors, found that they open smoothly and close at a slower rate. Resident interviews showed mixed opinions, with some stating the doors are light, but could be cumbersome or heavy for other residents. The facility confirmed they have had the same doors since licensure in 2018. Interview with residents provided that 2 out of 4 residents interviewed stated the doors were heavy for them. While automatic doors would be a beneficial service to the community who widely use walkers and wheelchairs, the doors are not out of Title 22 regulation compliance. Administrator noted that if they tighten them to close at an even slower rate it would cause the tension to be so great, they would be hard to open. Staff interviewed stated that some residents want to be independent and will not ask for help opening the doors or will wave them away to prevent help, but staff, especially in the dining area do watch for residents and try to aid. Administrator was reminded the facility needs to ensure residents’ needs are met. Based on records, interviews, and observations there is not a preponderance of evidence to prove the above allegations did or did not occur therefore the allegations are unsubstantiated at this time. An exit interview was conducted. A copy of this report was provided.