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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216803904
Report Date: 12/22/2021
Date Signed: 12/23/2021 08:40:09 AM



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
06/07/2021 and conducted by Evaluator Carla Fernandes-Goes
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20210607142605
FACILITY NAME:OAKMONT OF NOVATOFACILITY NUMBER:
216803904
ADMINISTRATOR:CAVE, JEFFFACILITY TYPE:
740
ADDRESS:1465 S NOVATO BLVDTELEPHONE:
(628) 215-1200
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY:118CENSUS: 82DATE:
12/22/2021
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Silvia Anaya - H&W DirectorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Resident's needs are not being met.

Facility staff has not received adequate training.
INVESTIGATION FINDINGS:
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The Department conducted a complaint investigation regarding the allegations listed above. Licensing Program Analyst Fernandes-Goes arrived unannounced for the purpose of closing the investigation and met with Annemarie Domizio - Executive Directo.

On 6/17/2021, LPA Fernandes-Goes open the complaint allegations listed above. During visit on 8/26/2021, LPA toured the facility; conducted interviews; acquired documentation; and made observations of the facility. In addition, during documentation review on file and interviews conducted 8/26, 10/18, and 12/14/21; Department learned that 1 out of 6 staff files reviewed has no 1st Aid on file. Staff S4 was hired on 10/26/21; business director reviewed staff file and was only able to provide Department with CPR training for staff S4. In addition, 1 out of 1 medication technician has no proof of medication shadowing training as required by H&S Code 1569.69.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 21-AS-20210607142605
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: 12/22/2021
NARRATIVE
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Facility wasn't able to provide Department with Staff S6 med. technician proof of medication shadowing training. Furthermore, 5 out of 5 caregivers have not complete the full required initial 14 hours of dementia training and/or have proof of complete initial 40 hours training as required by H&S Code 1569.625. (see documentation, LIC 809-D) Based on LPA’s interviews and files review, facility staff has not received all adequate training as required by Health & Safety Code.

In regard to “Resident’s needs are not being met”, Department acquired documentation on 8/26/21 for 4 resident’s, reviewed files and interviewed staff. According with residents' files reviewed and interviews, resident R1 has had “leg wound”,” “very moist”, and “complaint of pain” starting on 6/13/21 – doctor was contacted and no follow up and “history of skin condition and breakdown”, "bedridden" – physician’s assessment dated 10/15/2020; resident’s care notes 6/13/21 through 6/29/21 states that medication technician’s were taking care of wounds instead of a skilled professional nurse as required by Title 22 Regulations. Resident’s care notes states “Resident was in a good mood. RN Kristen gave an ointment/skin barrier for care staff to apply to R1’s buttocks…” and “Resident was cleaned, changed, applied barrier cream.” In addition, staff S8 during an interview on 12/20/21 stated the following “We were asked to take care of the wound for R1 until Home Health (HH) came in. It took about a week for HH to start coming in.”; “We were not supposed to do insulin ‘for resident R2’, but we did for a while until the corporation found out and changed that - around August.”; “We had to change the catheter bags, but we were not trained for that.” (see documentation, LIC 809-D) Based on documentation reviewed and interviews, resident’s needs are not being met and facility staff is being requested to execute care that is only allowed for skilled professionals in Title 22 Regulations.

According with complaint allegations " Resident's needs are not being met.” and “Facility staff has not received adequate training.” there were related observations made during visit. Based on LPA 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 $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 12/14/2021 through 12/22/2021 - Title 22 Regulations # 87411(a).
*****Total Civil Penalties issued today in the amount of $250.00.

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: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 21-AS-20210607142605
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: 12/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
01/05/2022
Section Cited
CCR
87411(c)(1)
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87411(c)(1)PERSONNEL REQUIREMENTS GENERAL; Staff shall receive first aid training from persons qualified by such agencies as the American Red Cross.This requirement is not met as evidenced by: Based
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Facility agrees to ensure that all staff working w/residents have an active 1st aid certification. Facility to review staff files and provide Department with a self certification that all staff has an active 1st aid certification and
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on record review & Interviews, the licensee did not comply w/the section cited above in 1 out of 6 staff 1st aid certification which poses potential health & safety or risk to persons in care. Department reviewed records & learned that staff S4 has no 1s aid certification on file.(see copies)
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at least 1 staff per shift has an active CPR certification by POC date of 1/5/2022 in order to clear this citation.
Type B
01/05/2022
Section Cited
CCR
87411(a)
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87411(a)Facility personnel shall at all times be sufficient in numbers, competent to provide the services necessary to meet resident needs...This requirement is not met as evidenced by: Based on
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Facility agrees to ensure that qualified staff will care for residents' according to their needs. Facility to provide Department with a plan on how facility staff will ensure that residents will have the qualified
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records review & interviews,the licensee did not comply w/the section cited above in 2 out of 4 resident needs which poses an immediate health & safety risk to persons in care. Dep. learned that residents R1 & R2 need a skilled professional to care for their needs and med. technicians w/out qualified training care for them.(see copies)
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professionals to care for their needs and proof of staff training with staff names, signatures, date, time, and trainer name by POC date of 1/5/2022. (Civil Penalties are being assessed in the amount of $250 due to a 2nd repeat citation issued for the same sections in less than 12 months.
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: 12/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 21-AS-20210607142605
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: 12/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
01/05/2022
Section Cited
HSC
1569.69
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§1569.69 Employees assisting residents with self-administration of medication; training requirements... This requirement is not met as evidenced by:Based on record review & interviews,the licensee did not
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Facility agrees to ensure that all medication technician staff has appropriated training with day, time, and amount of training hours on file. Facility to review staff files and provide Department with a self
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comply w/the section cited above in 1out of1 medication technician staff which poses a potential health & safety risk to persons in care.Dep. learned that S6 has no proof of shadowing training required on file.
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certification that medicaiton technicians have all required training on file to be reviewed by the Department and plan on how to track training by POC date of 1/5/2022 in order to clear this citation.
Type B
01/05/2022
Section Cited
HSC
1569.625(b)
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§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 5 out of 5
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Facility agrees to ensure that all caregiving staff has appropriated training with day, time, and amount of training hours on file. Facility to review staff files and provide Department with a self
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caregiver staff which poses a potential health & safety risk to persons in care. Department learned during staff files review that caregivers have not complete the full required initial 14 hours of dementia training and/or have proof of complete initial 40 hours training.
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self certification that caregivers have all required training on file to be reviewed by the Department and plan on how to track training by POC date of 1/5/2022 in order to clear this citation.
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: 12/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4