216803904-12-14-2021-21-AS-BMOS-CA6MVM-20211229085659

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216803904
Report Date: 12/14/2021
Date Signed: 12/14/2021 01:05:27 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
08/16/2021 and conducted by Evaluator Carla Fernandes-Goes

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20210816080359

FACILITY NAME:	OAKMONT OF NOVATO		FACILITY NUMBER:	216803904
ADMINISTRATOR:	CAVE, JEFF		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:	10:00 AM
MET WITH:	Annemarie Domizio - Executive Director		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Facility failed to meet residents hygiene needs resulting in pressure injury.

Food service is inadequate.

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 - ED.
On 8/26/21, LPA Fernandes-Goes toured the facility; conducted interviews; acquired documentation; and made observations of the facility. During documentation review on file and observations with Annemarie Domizio - ED for resident R1 on 8/26,10/18, and 11/9/21, and interviews of staff and complainant on 8/17, 8/26 and 10/18/2021, LPA learned that facility resident R1 has had bottom blisters on 6/23/2021 observed by staff in which doctor was contacted on 6/23 & 6/24/21. Physician order Home Health for wound care on 6/24/2. Per resident’s 1 care notes “wound looks dry” on 6/27/21. Care Notes for resident R1 also state a reediness on labia dated 8/10/21 and rash under breast dated 8/17/21. (Continue LIC 9099-C)

Unsubstantiated

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-20210816080359

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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At both occasions prescribed medication cream was applied and rashes were “was dry” on 8/18/21. Facility has no records for showers and or diaper change during this time. There is a doctor’s orders for repositioning that dates 8/25/21 every two hours which was discontinued by facility nurse staff on 9/30/21 and a new order for changing diapers every two hours dated 9/10/21. (copy of documentation on file) Based on documentation review and interviews, LPA wasn’t able to prove or disprove that facility failed to meet residents' hygiene needs resulting in pressure injury for the period of resident R1 moving in and complaint date.

In regard to food service is inadequate, facility provides facility residents with breakfast, lunch, dinner, and snacks. Resident R1 is “able to feed self” as per physician’s report (LIC 602) dated 10/15/2020 and has tray service 3x a day as per care plan dated 11/11/2020. Facility has no records for when meals are served to residents and if resident has eaten their meals. (copy of documentation on file)

A finding that the complaint allegations of “Facility failed to meet residents hygiene needs resulting in pressure injury.” and “Food service is inadequate.” are unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

No deficiencies cited during this inspection.

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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