216803904-2-8-2022-21-AS-CFGS-CBFQ5U-20220208105231

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216803904
Report Date: 02/07/2022
Date Signed: 02/08/2022 10:52:44 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

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:	DATE:	02/07/2022
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:			TIME COMPLETED:	01:45 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 conducted an unannounced Case Management Non-Compliance visit to this facility was welcome by front door staff and met with Annemarie Diomizio – Executive Director. Facility has 79 residents with 50 in assisted living and 29 in memory care ;13 of these residents are under Hospice care at this time. Facility has a calendar with activities in assisted living by activity room and elevator, and in memory care by dining room. Facility tour/inspection began at 9:14 AM: LPA toured the facility on 2/7/2022 at 9:14 AM with Annemarie Diomizio Executive Director; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. A sample tour of resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing. Fire Extinguisher was found to be last charged on 9/2021. There are emergency lights in many of the fixtures in the common areas of the facility that come on should a power outage occurs. All bathrooms designated for residents at the facility were supplied with towels and hand soap dispensers when a private room. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. Hot water temperature measured between 113.3 degrees F and 119.5 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 4 of 4 resident’s bathroom faucets. Toxins are stored in a locked housekeeping room. There was a supply of cleaners, hygiene products and paper products available for residents. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. During this inspection, menus are available and provided during meals. LPA observed that provisions are made for individuals with special dietary needs; facility keeps a variety of items on the menu, and facility has a board in the kitchen with a picture of the resident & a list of dietary needs. Food is available for residents any time of the day. There is a daily activity schedule for residents. The facility has special care plan of operation and programming for residents with dementia. Alarms in memory care and assisted living were tested during this visit. (see LIC 812 observations) Continue LIC 809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2022

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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: OAKMONT OF NOVATO	FACILITY NUMBER: 216803904
	VISIT DATE: 02/07/2022

NARRATIVE

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File Review began at 12:45 PM:
A sample review residents and staff were conducted. LPA learned that 4 out of 4 residents t have an updated care plan and complete medical assessment. Medications were centrally stored in a locked medication cart in the facility medication room. In addition, LPA reviewed a sample of staff files and learned that 1 out of 4 staff files have all training required (see LIC 809-D, civil penalty, and confidential name list). Staff S1 was hired on 10/2020 as a housekeeper and has been promoted to caregiver since 3/7/2021 In addition, facility has no training on file for agency staff at this time.

During this visit LPA reviewed and gathered more information for incident reports that have been submitted by the facility. Department has learned that on 12/31/2021 resident R1 received all the medication that was to be dispensed for another resident during night shift. Facility contacted 911, resident R1 was taken to ER and returned next day. Staff S2 has received all training required and has worked in the facility since 10/2021 at this time. There are no records that staff S2 has been retrained.

Civil Penalties are also being assessed in the amount of $250 due to a 2nd repeat citation issued for the same sections in less than 12 months. Today's assessment of $250.00 is for the period of 12/22/2022 through 2/7/2022 - Health & Safety Code # 1569.625(b)

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: 02/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2022

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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: OAKMONT OF NOVATO	FACILITY NUMBER: 216803904
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/07/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/08/2022 Section Cited	1 2 3 4 5 6 7	87465(a)(5)Incidental Medical and Dental Care Services. The licensee shall assist residents with self-administered medications when needed.This requirement isnot met as evidenced by:**Based on staff nterview, inc. report, &
	8 9 10 11 12 13 14	documentation review facility staff didn't comply w/section cited above in 1 out 1 residents medications as ordered/prescribed by Physician which poses an immediately health & safety risk to residents in care.	8 9 10 11 12 13 14	how to pass medication and submit by 2/8/22 schedule for S1 training that must be conducted withing two weeks maximum. In addition, facility to submit name of trainer,date,time, & signedt to CCL in order to clear this citation.
Type B 02/21/2022 Section Cited	1 2 3 4 5 6 7	§1569.625(b) Staff training; legislative findings…This requirement is not met as evidenced by:Based on record review & interviews,the licensee did not comply w/the section cited above in 1 out of 4
	8 9 10 11 12 13 14	caregiver staff in addition to 3 agency staff which poses a potential health & safety risk to persons in care. Department learned during staff training review that S! have no proof of Restrict conditions on file and agency staff have no proof of training.	8 9 10 11 12 13 14	certification that caregivers including agency staff have all required training on file to be reviewed by the Department and plan on how to track training by POC date of 2/21/2022 in order to clear this citation. (CP)

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: 02/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2022

LIC809 (FAS) - (06/04)

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