216803904-3-4-2022-21-AS-CFGS-CC7N96-20220304091524

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216803904
Report Date: 03/03/2022
Date Signed: 03/04/2022 09:15:32 AM

Document Has Been Signed on 03/04/2022 09:15 AM - It Cannot Be Edited

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: 82	DATE:	03/03/2022
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Annemarie Domizio - Executive Director		TIME COMPLETED:	03:00 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 opening a complaint investigation. During complaint investigation visit LPA met with ED AnneMarie Domizio, toured parts of the facility, reviewed and obtained records for residents & staff; conducted interviews and made observations. Facility has 82 residents with 29 in memory care, and from 29 in memory care there are 3 under hospice. During facility tour at 13:00 hour with ED Annemarie Domizio, LPA observed that 3 out of 6 resident's bedrooms were not clean. Resident R1's room had clothes on the floor and bed had sheets pullout. ED stated that resident had an accident and room had not been cleaned yet. In addition, resident R2 had clothes all over the floor, bed not done, and a duty diaper on the top of toilet flush; and resident R3 had several duty Q-tips and tissue cleaner around the room. (see pictures, LIC 809-D) LPA reviewed files and observed that resident R1 was admitted on 11/23/2021 and has an LIC 602 dating 10/15/2021 without TB test results and/or clearance. LPA interviewed staff who wasn't able to find the documentation needed. R1's attached documentation to LIC 602 states "there is no flow sheet data to this plate". (see copies, LIC 809-D) LPA observed on 3/3/2022 at 13:00 hour that memory care had 5 care staff with 1 being from an agency and 1 med tech; and at 15:00 hour facility memory care had 5 care staff with 4 being from an agency and 1 med tech. Records indicated that 4 out of 5 agency care staff is not associated to the facility (S1, S2, S3, and S4) with S4 also having fingerprint clearance pending. Facility understands that all staff needs to be associated to the facility and fingerprint cleared before working, residing , and/or volunteering. Staff S1, S2, S3 must be associated immediately and S4 may not work and/or be present at the facility until fingerprint cleared and associated. Facility still working around training staff S1 has no proof of training on file, and S2, S3, and S4 only Facility Orientation is on file. (see copies, LIC 809-D) 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: 03/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

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: 03/03/2022

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This visit will be finished virtually on 3/4/2022 to deliver citations and civil penalties.

Department is requesting the following to be submitted by 3/4/2022 at 12:00 PM:
- proof of follow up for resident R2 regarding "Shower Skin Sheet" on 2/24/2022 - more information.
- proof of follow up for resident R3 regarding "Report of Fall" sent to physician on 2/14/2022 more information.
- total number of residents under hospice care.

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: 03/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

LIC809 (FAS) - (06/04)

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