Inspection Reports for
The Oaks at Paso Robles

The complaint was substantiated based on interviews and evidence showing that the Administrator spoke inappropriately to a resident, causing discomfort and intimidation. The complaint control number is 29-AS-20251210162900.

The investigation substantiated the allegation that the Administrator at the time, Carl Meyer, spoke inappropriately to Resident #1 in a loud and heated conversation in the main lobby, causing discomfort to other residents and staff. Meyer admitted he should have handled the situation differently and no longer worked at the facility as of 1/14/2026.

The complaint was substantiated based on interviews and evidence showing that Administrator Carl Meyer spoke inappropriately to Resident #1, raising voices and blocking the resident's walker to prevent leaving. The incident caused discomfort to other residents and led to the resident withdrawing from normal routines. Meyer admitted he should have handled the situation differently and was no longer employed at the facility as of 1/14/2026.

The investigation substantiated the allegation that Administrator Carl Meyer spoke inappropriately to Resident #1 in the main lobby, raising voices and preventing the resident from leaving. This interaction caused discomfort among other residents and led to the resident feeling intimidated and withdrawing from normal activities. Meyer admitted mishandling the situation and no longer worked at the facility as of 1/14/2026.

The inspection found a deficiency related to medication documentation where nineteen centrally stored medications were not documented on resident records, posing a potential health and safety risk. The inspection was not completed and may be resumed later.

The complaint was substantiated. Allegations included neglect causing multiple UTIs for Resident #1, unsanitary facility conditions, and inadequate staffing. Evidence included interviews, record reviews, observations of soiled environments, and missing medication administration records. The facility was cited and assessed a $250 civil penalty for repeat violations.

The investigation substantiated all allegations: Resident #1 sustained multiple UTIs due to neglect and insufficient toileting assistance; the facility was found to be unclean and unsanitary with strong urine odors and stained belongings; and the facility was often understaffed, impacting resident care and supervision.

The complaint alleged neglect and lack of supervision resulting in multiple falls and injuries to Resident #1, and that food quantity was insufficient for residents. The neglect/lack of supervision allegation was substantiated, while the food quantity allegation was unsubstantiated.

The investigation substantiated that the facility failed to provide adequate supervision and care to Resident #1, resulting in multiple falls and injuries including fractures. The facility was often short-staffed and did not update the resident's service plan appropriately. A $500 civil penalty was assessed. The allegation regarding insufficient food quantity was unsubstantiated after observations and interviews.

The visit was triggered by a complaint/incident report regarding Resident #1 who was reported missing after leaving the facility unassisted. The incident occurred on 2025-08-24, and the facility reported it to the licensing agency nine days later, which is a violation. The complaint was substantiated with findings of delayed notification and inadequate staff training.

The facility failed to notify the licensing agency within the required timeframe after the elopement incident, and an agency staff member assigned to the memory care unit did not have the required dementia training. The facility's elopement protocols and door egress devices were reviewed and found functioning properly.

The visit was triggered by a complaint/incident report regarding Resident #1 who was reported missing on 08/24/2025 after leaving the facility unassisted. The complaint was substantiated by findings that the facility did not notify the licensing agency timely and failed to provide dementia training to agency staff.

The facility failed to notify the licensing agency within the required timeframe after the elopement incident, and an agency staff member assigned to the memory care unit did not receive required dementia training prior to working there.

The complaint investigation was substantiated regarding the lack of toilet paper and soap in resident bathrooms. Other allegations about lack of activities and unmet oral hygiene needs were unsubstantiated.

The investigation substantiated that supplies necessary for maintenance of adequate hygiene practice, including soap and toilet paper, were not readily available to each resident, posing potential health and safety risks. Allegations regarding lack of activities and unmet oral hygiene needs were found to be unsubstantiated.

The complaint investigation was substantiated for allegations of delayed staff response to resident calls, unclean linens, and facility odor issues related to a resident urinating in their room. Other allegations regarding soiled clothing, call button accessibility, and unmet resident needs were unsubstantiated.

The investigation substantiated that staff did not always respond to resident calls within 10 minutes, with multiple calls exceeding 20, 30, and 60 minutes. Several resident rooms were found with soiled linens and mattresses. A resident's room in memory care had a strong urine odor and visible damage due to urination. Other allegations such as staff leaving a resident in soiled clothing, call button accessibility, and staff not meeting residents' needs were found unsubstantiated.

The visit was complaint-related due to a medication error where Resident 1 was given Resident 2's medication. The error was self-reported by the facility. Staff 1 was temporarily suspended and later resigned. The facility had a prior medication error citation with a plan of correction completed before this incident.

The facility was found to have committed a medication error posing an immediate health and safety risk when Staff 1 administered the wrong medications to Resident 1. Additionally, centrally stored medications for Resident 2 were not properly recorded, indicating noncompliance with medication storage and recordkeeping requirements.

The visit was complaint-related due to a medication error self-reported by the facility. Staff 1 administered the wrong medications to Resident 1, who was subsequently taken to the hospital and returned to the facility the same day. The medication error was substantiated.

The facility was found to have a medication error where Staff 1 gave the wrong medications to Resident 1, posing an immediate health and safety risk. Additionally, centrally stored medications for Resident 2 were not properly recorded. Staff 1 was suspended and resigned effective 04/06/2025.

The complaint was substantiated. The allegation was that staff did not administer residents' medication, specifically Resident 1, over a period from July 2023 through October 2024. Evidence included interviews, medication audits, and physical medication counts confirming missed medication doses.

The investigation substantiated the allegation that Resident 1 was not administered medication as prescribed over approximately 398 days. Medication audits revealed significant discrepancies between medication administration records and physical medication counts, indicating multiple missed medication doses.

The complaint was substantiated regarding unsanitary conditions due to ammonia and fecal odors in Resident 1's room. Other allegations about dietary needs, incontinence care, safe environment, and activities were unsubstantiated.

The complaint investigation substantiated that staff did not ensure the facility was maintained sanitary due to overwhelming ammonia odor and fecal matter in a resident's room. Other allegations regarding dietary needs, incontinence care, safe environment, and provision of activities were found unsubstantiated based on interviews, observations, and documentation.

The facility was generally found to be in good repair with proper equipment and safety measures in place. One citation was issued due to a resident file missing a Tuberculosis Test, but no other violations or technical issues were noted.

The complaint investigation was substantiated for the allegation that staff did not follow COVID-19 protocols due to the administrator allowing a family member to enter through an unscreened exit door during June and July 2022. The allegations of insufficient staffing and cleanliness were unsubstantiated.

The allegation that staff did not follow COVID-19 protocols was substantiated based on interviews and admissions that the administrator allowed a family member to circumvent screening protocols. The allegations of insufficient staffing and the facility not being kept clean and sanitary were unsubstantiated based on documentation, interviews, and observations.