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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803904
Report Date: 12/22/2021
Date Signed: 12/23/2021 08:38:25 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 NOVATOFACILITY NUMBER:
216803904
ADMINISTRATOR:DOMIZIO, ANNEMARIEFACILITY TYPE:
740
ADDRESS:1465 S NOVATO BLVDTELEPHONE:
(628) 215-1200
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY:118CENSUS: 82DATE:
12/22/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Silvia Anaya - H&W DirectorTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Fernandes-Goes arrived unannounced with the purpose of closing a complaint investigation. During subsequent complaint investigation LPA learned there are related deficiencies observed during the visit. LPA met with Annemarie Domizio - Executive Director . Following item were observed during investigation visits:

LPA reviewed files for 4 residents and learned that 2 out of 4 resident’s care notes states “Resident was in a good mood. RN Kristen gave an ointment/skin barrier for care staff to apply to R1’s buttocks…” and “Resident was cleaned, changed, applied barrier cream.” In addition, staff S8 during an interview on 12/20/21 stated the following “We were asked to take care of the wound for R1 until Home Health (HH) came in. It took about a week for HH to start coming in.”; “We were not supposed to do insulin ‘for resident R2’, but we did for a while until the corporation found out and changed that - around August.”; “We had to change the catheter bags, but we were not trained for that.” Facility staff is being requested to execute care that is only allowed for skilled professionals in Title 22 Regulations (see documentation, LIC 809-D)

In addition, LPA reviewed incident reports and SOC 341s that have been submitted to the Department by the facility. Department is requesting copy of investigation conducted on SOC 341 for resident R3.

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: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 12/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/05/2022
Section Cited

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87613 General Requirements for Restricted Health Conditions. This requirement is not met as evidenced by: Based on record review & Interviews, the licensee did not comply w/the section cited above in 2 out of 2
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residents restricted care needs which poses potential health & safety risk to persons in care. Department reviewed records, conducted interviews and learned that facility unqualified staff was caring for R1 & R2's restricted conditions.
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files and provide Department with a list of residents in care that have a restricted condition, their condition, plan of care for condition, & skilled professional contacted by POC date of 1/5/2022 in order to clear this citation.

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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: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2021
LIC809 (FAS) - (06/04)
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