<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803904
Report Date: 12/14/2021
Date Signed: 12/14/2021 01:16:17 PM

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: 81DATE:
12/14/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Annemarie Domizio - Executive DirectorTIME COMPLETED:
01:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
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 observed during resident’s R1 file review and interviews on 10/18 and 11/9/2021 that resident R1’s physician report dated 10/15/2020 with a diagnostic of dementia. Per Title 22 Regulations # 87705 Care of Persons w/ Dementia “Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.” (see copy of documentation, LIC 809-D)

In addition, resident R1 had a doctor’s orders dated 8/25/2021 for “repositioning every two hours”. Doctor’s orders did not start according with MARs (Medication Administration Records) until 9/18/2021 which was stopped on 9/30/2021 by facility staff without doctor’s orders to discontinued. Furthermore, according with MARs resident wasn’t reposition every two hours between 9/18/21 and 9/30/21. On 9/10/2021 resident R1 received an order for “changing diaper every two hours” which didn’t start according with MARs until 9/23/2021. (see copy of documentation, LIC 809-D)

Furthermore, according with file reviews and interviews on 10/18/2021, LPA learned that resident R2 had a fall on 8/5 in which resident 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”; and was sent with a family member to the ER due to facility "observed wound getting worse complaining of pain, wound looks very red and had pus in it.”, however; no incident reports were submitted to CCLD (Community Care Licensing Division) as required on Title 22 Regulations # 87211 Reporting Requirements.
Continue LIC 809-D
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 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.
LIC809 (FAS) - (06/04)
Page: 1 of 4
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
VISIT DATE: 12/14/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
In addition, Resident R3 MARs (Medication Administration Records) states that resident has refused medications 4 out of 6 months however; no report was submitted to the Department.(see records, LIC 809-D)

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: 12/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: 12/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
12/15/2021
Section Cited

1
2
3
4
5
6
7
87411(a)Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based on record
8
9
10
11
12
13
14
review,the licensee did not comply w/the section cited above in 1 out of 1 resident needs which poses an immediate health & safety or risk to persons in care. LPA learned that R1 had a doctor’s orders dated 8/25/21 for “repositioning every 2 hours”. Doctor’s orders didn't start according with MARs until 9/18/2021 which was stopped on 9/30/21 by facility staff without doctor’s orders to dc. In additionaccording w/ MARs resident wasn’t reposition every 2 hours between 9/18/21 and 9/30/21. On 9/10/2021 resident R1 received an order for “changing diaper every two hours” which didn’t start according with MARs until 9/23/2021. (see records on file)
8
9
10
11
12
13
14
meet all services necessary to meet residents' needs at all time by POC date of 12/15/21 in order to clear this citation.
Type B
12/28/2021
Section Cited

1
2
3
4
5
6
7
87705(c)(5)Each resident with dementia shall have an annual medical assessment as specified in Section 87458...This requirement is not met as evidenced by:Based on record review & interview, facility didn't comply w/the section cited above in 1 out of 1 resident medical assessment which poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
comply w/the section cited above in 1 out of 1 resident medical assessment which poses a potential health,safety or personal rights risk to persons in care. Medical assessment on file for resident R1 dated 10/15/20 w/ diagnostic of dementia. (see records)
8
9
10
11
12
13
14
all medical assessments on file for residents with a diagnosis of dementia and/or change of condition have been updated according with this Title 22 Regulation to be submitted to CCLD by POC date of 12/28/21.
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: 11/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: 12/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
12/28/2021
Section Cited

1
2
3
4
5
6
7
87211 Reporting Requirements. This requirement is not met as evidenced by:Based on obs, record review, & interview the licensee did'ot comply with the section cited above in 2 out of 3 resident's incident reports which
8
9
10
11
12
13
14
poses a potential health, safety or personal rights risk to persons in care. LPA learned that R2 & R3 had incidents including refusal of medication while in care that were not reported to the Department. (see records on file)
8
9
10
11
12
13
14
a timely matter according with Title 22 Regulations and H&S Code. Facility to submit a self certification that staff/administrator understands reporting requirements and that facility will be in compliance by POC date of 12/28/21

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 MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 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
LIC809 (FAS) - (06/04)
Page: 4 of 4