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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216803904
Report Date: 12/14/2021
Date Signed: 12/15/2021 08:46:50 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
11/10/2021 and conducted by Evaluator Carla Fernandes-Goes
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20211110120306
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
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Annemarie Domizio - Executive Director TIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Resident was unlawfully evicted while in care
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 11/15/21 & 11/22/21, LPA Fernandes-Goes conducted interviews, acquired documentation, and made observations of the facility. During documentation review on file and interviews conducted, Department learned that resident R6 was evicted on 9/14/2021 due to a change of condition stating “At the time of move in R6 was able to self-administer her own insulin and blood glucose checks. At this time however R6 is no longer able to perform self-administrator of the insulin.”.

Continue LIC 9099-C
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: 12/14/2021
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)
Page: 1 of 3
Control Number 21-AS-20211110120306
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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However, facility on 7/14/2021 conducted a review updated care plan with responsible party in which the change of condition was reviewed and plan was in place for resident R6 as it states “Outside Providers, non-hospice: Requires services from an outside provider with minimal staff assistance and coordination of care by community nurse – Receives services from an outside provider…” (copy of records on file) Based on interviews and records review, facility was aware of change of condition on 7/14/2021 and had a care plan in place to meet the needs of the resident R6 which makes eviction unlawful since no other change of condition occurred in between 7/2021 and 9/2021 as per records and interviews. (see LIC 9099-D)

According with complaint allegation “Resident was unlawfully evicted while in care.” there was related observations made during visit. Based on LPAs' observations, interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

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
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 21-AS-20211110120306
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)
Request Denied
Type B
12/28/2021
Section Cited
CCR
87224(a)
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87224(a)The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through(5).This requirement isn't met as evidenced by: Based on documentation review
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Facility to ensure that Title 22 Reg. #87224 Eviction Procedures is followed at all times. Facility agrees to review eviction procedures and submit a self certification
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& interviews,the licensee didn't comply w/section cited above with at least 1 outof 1 resident in care which poses a potential risk for residents in care. Department learned that resident R6 was evicted on 9/14/21 & careplan w/change of condition was conducted signed and arrangements done on 7/14/2021
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 to CCLD by POC date of 12/28/21 in order to clear this citation.
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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
LIC9099 (FAS) - (06/04)
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