216803904-12-14-2021-21-AS-BMOS-CA6MYG-20211229090132

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216803904
Report Date: 12/14/2021
Date Signed: 12/14/2021 01:10:07 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
08/23/2021 and conducted by Evaluator Carla Fernandes-Goes

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20210823100922

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:	10:30 AM
MET WITH:	Annemarie Domizio - Executive Director		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Facility staff failed to meet resident’s needs.

Facility staff failed to seek timely medical for resident in care.

Facility signal system is in disrepair.

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 8/26/21, 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 from 8/17/2021 until 8/23/2021 and observations, LPA learned that resident R2 alarm rang 26 times from which 21 had no response; and 1 x 12 min, 1 x 23 min, and 1 x 35 min to be answered. In addition, on 8/26 LPA pressed the alarm in residents’ bathrooms with residents in the room and 3 out of 4 times no staff answered the call alarm. ED stated that after speaking with staff she learned that one caregiver had the beeper without battery - believe to be battery needed, and the other wasn't ringing.
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-20210823100922

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 A 12/15/2021 Section Cited CCR 87464(d)	1 2 3 4 5 6 7	87464 Basic Services(d)A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal and providing the other basic services...	1 2 3 4 5 6 7	Facility to ensure that residents' needs are met all the time. Facility to submit self certification that residents' needs will be met as needed and information on how facility will ensure that call alert will
	8 9 10 11 12 13 14	This requirement is not met as evidenced by:Based on interviews,records review,& obs, licensee didn't comply w/section cited above with at least 1 outof 1 resident care & answering alarm system which poses an immediate risk to their health and safety. (see records)	8 9 10 11 12 13 14	be answered and residents' needs will be met in a timely matter to CCLD by POC date of 12/15/2021 in order to clear this citation.
Type A 12/15/2021 Section Cited CCR 87465(g)	1 2 3 4 5 6 7	87465(g)Incidental Medical and Dental Care Services.This requirement isn't met as evidenced by: **Based on docs review & interviews facility didn't comply w/reg above on 1of1 resident which poses an	1 2 3 4 5 6 7	Facility to revise plan & procedure regarding residents medical attention provided to CCLD on 7/2/21 and a self certification that facility will ensure that residents' medical and dental attention needed will
	8 9 10 11 12 13 14	immediateHealth & Safety risk to resident in care.Resident R2 had a fall had a fall on 8/5 & 8/6/21 had a skin tear on right leg and pain on her left shoulder. On 8/12/21 resident’s R2 carenotes, staff “upon change of bandage to “R” lower leg skin tear noted from post fall… area not healing. Skin tear noted & blood… resident confused”;on 8/14/21 facility “observed wound getting worse complaining of pain,wound looks very red and had pus in it.” Family tood resident R2 to ER on 8/14/21. (copies on file)	8 9 10 11 12 13 14	be done in a timely matter to be submitted to CCL by POC 12/152021. In addition, facility to submit proof of staff training on procedures submitted by 12/28/21 in order to clear this citation. (Civil Penalties)

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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Control Number 21-AS-20210823100922

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 87303(a)	1 2 3 4 5 6 7	The facility shall be clean, safe, sanitary & in good repair at all times. Maintenance shall include provision of maintenance services & procedures for the safety and well-being of residents, employees & visitors.	1 2 3 4 5 6 7	Facility to ensure that facility call alert, button,& motion alert is working at all times and that facility staff will respond to calls in timely matter. Facility to submit a self certification that call system is working
	8 9 10 11 12 13 14	This requirement is not met as evidenced by:Based on obs, record review & interview, the licensee did not comply with the section cited above in 1 out of 1 facility call alert which poses/posed a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14	properly in addition to facility having appropriate staff to answer resident's calls in a timely matter by POC due date of 12/28/21 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: 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)

Page: 3 of 5

Control Number 21-AS-20210823100922

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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Furthermore, per resident R2 care notes on 7/26/21 staff stated that “Resident’s pendant is not registering in the pager. Care staff also tested out the pager to confirm that the pager is not registering the pendant...” (see documentation, LIC 809-D) Based on observation and record review, facility has failed to meet resident R2 needs and alarm system is in disrepair.

In regard to “Facility staff failed to seek timely medical for resident in care.”& “Facility staff failed to meet resident’s needs.”, LPA learned that according with records review provided by facility that resident R2 had a fall on 8/5/21 had a skin tear on right leg and pain on her left shoulder at 10:15 PM resident was “sloping”; on 8/6/21 resident R2 had another fall in dining room and was observed “shaking and not stable on long walk”. On 8/12/2021 per resident’s R2 care notes, staff “upon change of bandage to “R” lower leg skin tear noted from post fall… area not healing. Skin tear noted & blood… resident confused”; 8/13/21 discoloration was found on resident’s R2 left lower arm from the previous fall; on 8/14/21 facility “observed wound getting worse complaining of pain, wound looks very red and had pus in it.” Between 8/5/21 and 8/13/21 facility did not send resident R2 to ER and/or received doctor’s response to fax report of fall on 8/5 & 8/6/21. Facility failed to meet resident's needs. In addition, facility did not submit any incident reports for resident R2 to CCLD (Community Care Licensing Division) regarding falls or visit to ER on 8/14/21 with family member. Hospital discharge documentation for resident R2 dating 8/14/2021 states need to follow up instructions for wound care for skin tear, abrasion, and cellulitis with the following cause for resident R2 “Caused by bacteria… ‘which’ enter through a break in the skin.”(see records, LIC 809-D, Civil Penalty)

Continue LIC 9099-C

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)

Page: 5 of 5

Control Number 21-AS-20210823100922

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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According with complaint allegations " Facility staff failed to meet resident’s needs.”; “Facility staff failed to seek timely medical for resident in care.”; and “Facility signal system is in disrepair.” there were related observations made during visit. Based on LPAs' observations 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.

Civil Penalties are also being assessed in the amount of $1,000 due to a violation that the department determines resulted in the injury or illness of a person in care and is a repeat violation in the last 12 months - 6/17/2021 through 12/14/2021 Title 22 Regulation
# 87465(g).

*****Total Civil Penalties issued today in the amount of $500.00.

The licensee was informed that additional civil penalties are under review by the Department per Health and Safety Code 1569.49 (f).

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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