216803904-6-17-2021-21-AS-CFGS-C43VB2-20210617161649

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216803904
Report Date: 06/17/2021
Date Signed: 06/17/2021 04:16:59 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 NOVATO		FACILITY NUMBER:	216803904
ADMINISTRATOR:	CAVE, JEFF		FACILITY TYPE:	740
ADDRESS:	1465 S NOVATO BLVD		TELEPHONE:	(628) 215-1200
CITY:	NOVATO	STATE: CA	ZIP CODE:	94947
CAPACITY:	118	CENSUS: 93	DATE:	06/17/2021
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Jeff Cave - Regional Executive Director Specialist		TIME COMPLETED:	03:30 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	License Program Analyst (LPA) Fernandes-Goes arrived unannounced to conduct a post licensing & infection control required visit of the facility. LPA was welcomed by Juan Ferrel - Business Director; Jeff Cave arrived during this visit There is a total of 62 residents in assisted living, and 31 residents in memory care. There are 3 residents under Hospice care. Facility tour/inspection began at 9:10 AM: LPA toured the facility on 6/17/2021 at 9:10 AM with Juan Ferrel Business Director; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on 6/2020. Facility smoke detectors are hard wired and sound directly to the fire station. Smoke detectors and fire sprinklers are inspected annually, and inspection records are current. LPA did a sample test of 4-bedroom single smoke detectors and Carbon monoxide that were found to be operational. There are emergency lights in many of the fixtures in the common areas of the facility that come on should a power outage occurs. Hot water temperature measured between 113.3 degrees F and 122.5 degrees F failing out of Title 22 acceptable regulation of 105 to 120 degrees F in 4 of 10 resident’s bathroom faucets. (see LIC 809-D) The facility has special care plan of operation and programming for residents with dementia. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. During this inspection, LPA observed food stored in main kitchen & memory care refrigerator weren’t properly stored. (see pics, LIC 809-D) 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. (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: 06/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021

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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: OAKMONT OF NOVATO	FACILITY NUMBER: 216803904
	VISIT DATE: 06/17/2021

NARRATIVE

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Food is available for residents any time of the day. There is a daily activity schedule for residents. Toxins are stored in a locked housekeeping room. There was a supply of cleaners, hygiene products and paper products available for residents. 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. A sample tour of resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing.

File Review began at 12:30 PM:
A sample review of ten residents was conducted. LPA learned that 3 out of 10 residents don’t have a pre-appraisal and 2 out of 10 have an incomplete medical assessment. (see copies on file, LIC 809-D) Medications were centrally stored in a locked medication cart in the facility medication room. In addition, LPA observed during facility tour with Business Director that 3 out of 10 residents had unlocked medications in their bathroom which according to their LIC 602 – physician’s assessment aren’t “able to administer own prescription medications, able to administer own PRN medications, or able to store own medications.”; 2 out of 3 have a diagnostic of dementia.

LPA met with ED Jeff Cave, Amanda Phimsipasom Transitions (Memory Care) Director, and Leann Mendoza Resident Care Coordinator regarding concerns that were observed during this visit. This visit will need to be continue at another date when deficiencies and infection control assessment will be contacted.

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.
There were no deficiencies cited at this time.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021

LIC809 (FAS) - (06/04)

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