216803904-2-26-2021-21-AS-KMOA-BZ2N3M-20210312090630

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216803904
Report Date: 02/26/2021
Date Signed: 02/26/2021 01:00:50 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/27/2021 and conducted by Evaluator Carla Fernandes-Goes

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20210127172907

FACILITY NAME:	OAKMONT OF NOVATO		FACILITY NUMBER:	216803904
ADMINISTRATOR:	RIVERA, MELON		FACILITY TYPE:	740
ADDRESS:	1465 S NOVATO BLVD		TELEPHONE:	(628) 215-1200
CITY:	NOVATO	STATE: CA	ZIP CODE:	94947
CAPACITY:	118	CENSUS: 75	DATE:	02/26/2021
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Melon Rivera - Executive Director		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff not administering medications as prescribed.

INVESTIGATION FINDINGS:

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The Department conducted a complaint investigation regarding the allegation listed above. Licensing Program Analyst Fernandes-Goes conducted an unannounced telephone call visit due to COVID-19 for the purpose of closing the investigation and met with Melon Rivera – Executive Director.

On 2/4/2021 at 12:00 PM, LPA Fernandes-Goes toured the facility medication rooms; conducted interviews; acquired documentation; reviewed and made observations of medications. During tour of the facility with Kristin Bourne Health Services Director (HSD) & Melon Rivera Executive Director; interviews with 2 of 2 staff on 2/4/2021 and complainant on 1/28/2021, LPA learned that resident R1 & R2 have had medications that weren’t administer as prescribed by the doctor.
CONTINUE LIC 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20210127172907

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: OAKMONT OF NOVATO	FACILITY NUMBER: 216803904
	VISIT DATE: 02/26/2021

NARRATIVE

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On 11/29/20 resident R1 received 24 units of insulin at AM by facility staff and again 24 units at PM by Home Health Nurse who requested medication and had it provided by medication technician staff – doctor’s prescription states 22 units if glucose < 200 and 24 units if glucose > 200 every morning at the time medication was administered. In addition, resident R2 on 11/15/20 received a prescribed medication Zolpiem 5 mg at 8:19 PM and at 11:12 PM – doctor’s prescription states 5 mg within 24 hours. In both occasions doctors and family were contacted. In the case of resident R1 & R2, facility staff didn’t administer medications according with doctor’s orders. (see confidential name list, copy of documentations, LIC 809-D)

Furthermore, LPA observed a medication for R1 & another for R3 that were not entered on Centrally Stored Medication Form (CSMR). LPA requested medications to be entered during visit and for facility to have a plan on how they will ensure that all medications are entered after being delivered to facility.

According with complaint allegation "Staff not administering medications as prescribed.” there were related observations made during visit. Based on LPA observation and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

Appeal of Rights Given.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2021

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20210127172907

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: OAKMONT OF NOVATO	FACILITY NUMBER: 216803904
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/26/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/27/2021 Section Cited CCR 87465(a)(5)	1 2 3 4 5 6 7	87465(a)(5)Incidental Medical and Dental Care Services. The licensee shall assist residents with self-administered medications when needed.This requirement isnot met as evidenced by:**Based on staff	1 2 3 4 5 6 7	Facility to ensure that staff will follow phisicians' orders when assisting residents self administration of medications. Facility agrees to conduct staff training on Medications for med. techs.
	8 9 10 11 12 13 14	interviews, inc. reports, & documentation review facility staff did not comply with the section cited above in 2 out of 2 residents medications as ordered/prescribed by the Physician which poses an immediately health & safety risk to residents in care.	8 9 10 11 12 13 14	Facility must submit by 2/27/21 schedule of training that must be conducted withing two weeks maximum. In addition, facility will submit topics, name of trainer, date, time, and signing sheet to be provided to CCL in order to clear this citation.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Carla Martinez	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2021

LIC9099 (FAS) - (06/04)

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