216803904-12-14-2021-21-AS-BMOS-CA6N5S-20211229091002

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216803904
Report Date: 12/14/2021
Date Signed: 12/14/2021 01:13:21 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
09/14/2021 and conducted by Evaluator Carla Fernandes-Goes

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20210914154950

FACILITY NAME:	OAKMONT OF NOVATO		FACILITY NUMBER:	216803904
ADMINISTRATOR:	DOMIZIO, ANNEMARIE		FACILITY TYPE:	740
ADDRESS:	1465 S NOVATO BLVD		TELEPHONE:	(628) 215-1200
CITY:	NOVATO	STATE: CA	ZIP CODE:	94947
CAPACITY:	118	CENSUS: 81	DATE:	12/14/2021
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Annemarie Domizio - Executive Director		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff do not respond to the resident pushing her pendent in a timely manner.

INVESTIGATION FINDINGS:

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The Department conducted a complaint investigation regarding the allegation listed above. Licensing Program Analyst Fernandes-Goes arrived unannounced for the purpose of closing the investigation and met with Annemarie Domizio - Executive Director

On 9/23/21, LPA Fernandes-Goes toured the facility; conducted interviews; acquired documentation; and made observations of the facility. During documentation review on file for history of alarm for 9/11/2021 and interviews conducted on 9/23/21, LPA learned that resident R4 & R5 in assisted living rang the alarm rang 2 times which was announced 16 times at 10:35 PM. Record states “Response required but not received as of 11:15 PM. This alert was never responded to.” (copy on file)
Continue LIC 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2021

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-20210914154950

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: 12/14/2021

NARRATIVE

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Per residents' R4 & R5’s records, resident R4 care plan states “Fall risk will be managed through implementation of a fall management program. Interventions to manage fall risk.” dated 6/30/21 and resident R5 LIC 602 (physician’s assessment) dated 7/3/21 “motor impairment/paralysis” and care plan dated 7/3/21 “Resident is at risk for falling. Requires staff observation to promote safety”. (see copy of records, LIC 9099-D) Based on interviews and records review, facility staff did not respond to pendant in a timely manner causing residents' needs not to be met.

According with complaint allegation “Staff do not respond to the resident pushing her pendent in a timely manner.” there was related observations made during visit. Based on LPAs' observations, 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: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2021

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20210914154950

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: 12/14/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/28/2021 Section Cited CCR 87468.1	1 2 3 4 5 6 7	87468.1(2)Personal Rights:To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement isn't met as evidenced by: Based on documentation review &	1 2 3 4 5 6 7	Facility to ensure that call alarm system is in good repair and staff is sufficient to answer calls when residents are in need of assistance. Facility to submit a plan regarding all call system used at the facility
	8 9 10 11 12 13 14	interviews,the licensee didn't comply w/section cited above w/ at least 2 outof2 residents call alarm request not answere on 9/11/21 which poses a potential risk for residents in care. Department learned that resident R4&5 use call alarm on 9/11 at 10:35 PM which was never answered.	8 9 10 11 12 13 14	such as pendant, motion sensor, bathroom alert button and a detail information on how it will work, how it will be answered, who will be responsible to answer, and etc by POC date of 12/28/2021.
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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 Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2021

LIC9099 (FAS) - (06/04)

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