216803904-3-10-2022-21-AS-BMOS-CCJSKW-20220315135721

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216803904
Report Date: 03/10/2022
Date Signed: 03/10/2022 03:22:35 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/24/2021 and conducted by Evaluator Carla Fernandes-Goes

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20210824114946

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: 78	DATE:	03/10/2022
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Kathleen Olson - Executive Director		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Facility staff failed to respond to call system timely.

Facility failed to meet residents' needs.

Facility is understaffed.

Personal Rights.

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 Kathleen Olson - Executive Director.

On 8/26/2021, LPA Fernandes-Goes toured the facility; conducted interviews; acquired documentation; and made observations of the facility. During tour of the facility with Annemarie Domizio – Executive Director on 8/26/21, 10/18/21, and 3/3/22, interviews with complainants, residents and staff on 8/24/21, 10/4/21, 10/13/21,12/16/21, 12/27/21, 12/31/21, and 3/2/22; and documentation review, LPA learned that facility has a call system designed to attend residents in need.

Continued LIC 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/24/2021 and conducted by Evaluator Carla Fernandes-Goes

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20210824114946

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: 78	DATE:	03/10/2022
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Kathleen Olson - Executive Director		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Facility is not clean and sanitary.

Facility does not have an adequate supply of gloves to meet residents hygiene needs.

Facility failed to have resident’s records available after resident’s consent or that of his designated representative.

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 Kathleen Olson - Executive Director.

On 8/26/2021, LPA Fernandes-Goes toured the facility; conducted interviews; acquired documentation; and made observations of the facility. During tour of the facility with Annemarie Domizio – Executive Director on 8/26/21, 10/18/21, and 3/3/22, interviews with complainants, residents and staff on 8/24/21, 10/4/21, 10/13/21,12/16/21, 12/27/21, 12/31/21, and 3/2/22; and documentation review, LPA learned that facility had been understaffed for housekeeping 2 to 3 weeks and residents' rooms were not being clean.

Continued LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 9

Control Number 21-AS-20210824114946

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/10/2022

NARRATIVE

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Per some staff and residents interviews, residents' were contracting and paying outside housekeepers to ensure that their rooms were clean during these weeks. However, Department wasn’t able to prove or disprove that during these 2 to 3 weeks facility wasn’t clean and sanitary. In addition, during visit to facility on 3/3/2022 at 13:00 hour, LPA observed 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 Case Management report dating 3/3/22 and 3/10/22) Facility understands that premises most be clean, sanitary, and in good repair at all times.

In regard to, “Facility does not have an adequate supply of gloves to meet residents' hygiene needs.”, Department observed 3 boxes of gloves in memory care medication room and 8 boxes of gloves in Resident Care Director for Assisted Living office. In addition, ED Annemarie stated that there was an order of gloves coming in. Even though staff stated that they were bringing gloves from home to serve the residents', Department wasn’t able to prove or disprove that this had occurred. (see pictures)

Furthermore, complainant stated that “Facility failed to have resident’s records available after resident’s consent or that of his designated representative.” Per facility Health & Wellness Director Silvia A. facility provides records to POAs and family members as long as they are not internal records. Residents' that were interviewed had never requested records and were not able to attest to this allegation. Title 22 Regulations Residents' Records # 87506(c)(1) states that “…The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative.” Based on interviews, Department wasn’t able to prove or disprove that residents' records were not made available by the facility after being requested by a designated representative.

Continued LIC 9099-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20210824114946

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/10/2022

NARRATIVE

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A finding that the complaint allegations of "Facility is not clean and sanitary.”, “Facility does not have an adequate supply of gloves to meet residents hygiene needs.”; “Facility failed to have resident’s records available after resident’s consent or that of his designated representative.” is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

No deficiencies cited during this inspection.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20210824114946

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/10/2022

NARRATIVE

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Facility records from 8/8/21 to 8/12/21 indicates that facility responded to calls 38 % of the time under 10 minutes frame, 29.7 % between 11 minutes to 35 minutes frame, and residents had no response to their calls for 32.3 % of the time. In addition, on 8/26/21 LPA tested bathroom alerts in memory care and 3 out of 4 times calls were not answered after waiting for 15 minutes. Residents and complainants that were interview stated that they have waited up to 45 minutes for a call to be answered when they are answered. Per interviews, record reviews, and observation facility staff failed to respond to call system in a timely matter. In addition, residents' needs are not being met. (LIC 809-D)

In regards to, “Facility failed to meet residents' needs.”, “Facility is understaffed.”, “Personal Rights.”; facility had on 8/26/2021 33 residents in memory care, 4 care staff, and 1 med tech at the time of the visit. Per records provided by the facility and staff interviews conducted during this investigation, Department learned that facility has 4 care staff & 1 med tech during AM & PM shift, and 2 care staff on NOC shift with a med tech. Residents' care levels range from Level 1 to 5 in memory care. At this time facility has 12 res. Level 1, 3 residents Level 2; 3 residents Level 3, 8 residents Level 4, and 6 residents Level 5. Per care plans there are 22 res. w/ fall concerns; 33 need some kind of assistance w/ toileting (17 incontinence + 18 assistance in toileting) and showers with 17 in need of observation for skin breakdown; 8 res. are 2 people assist and 1 for 1-person assist; 6 residents' need repositioning; 22 fall concern; 4 under hospice care; 30 need help with grooming and dressing; 4 feeding assistance; 5 under a special diet; 24 needs reminders and escort when going to dining room to eat, and other ADLs; 20 need assistance for bedtime services; 13 need assistance w/ dentures, compression hose, and hearing aid; 1 has a catheter care; 1 on oxygen; and 1 under 3 to 4 checks per shift. Facility had a total of 4 residents under hospice care and 20 residents that needs redirection due to wander behavior. Shower schedule shows from Monday thru Sunday schedules of 4 showers on Sunday, 7 showers Monday, 5 showers Tuesday, 8 showers Wednesday and Friday 6 showers on Thursday, and 7 showers on Saturday. Facility has 4 caregivers on shift to conduct showers, status checks, meals, diapers, toileting, grooming, laundry and all other needs that my occur on each shift.

Continued LIC 9099-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20210824114946

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/10/2022

NARRATIVE

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According with second complainant facility incident report, resident R4 was found tied up to a chair at 21:00 hour, facility believed to be an agency care staff. Facility records indicate that care staff involved had no training on file and is no longer working at facility; family wasn’t contacted until next day around 15:00 hour. Resident R4 physician’s assessment (LIC 602) states that resident has a diagnostic of dementia with wandering behavior, sundowing behavior, and able to follow instructions. Per residents', call alert, and incident report for resident R4, facility failed to meet residents' needs; is understaffed; and violated resident’s R4 personal Rights. (see confidential name list, copy of records on file, LIC 809-D) Department also learned per interviews of residents', staff, and statement from resident council meeting that facility had no housekeeping for 2 to 3 weeks in the month of August 2021 and that Interviews revealed residents’ concerns/complaints were felt to be addressed in a forceful non-adequate manner and there was no communication regarding the status of housekeeping. Per residents', call alert, and incident report for resident R1, facility failed to meet residents' needs; is understaffed; and violated resident’s R1 personal Rights. (see confidential name list, copy of records on file, LIC 809-D)

According with complaint allegation "Facility failed to meet residents' needs.”, “Facility is understaffed.”, and “Personal Rights.” there were related observations made during visit. Based on LPAs' 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.

Continued LIC 9099-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20210824114946

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/10/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/24/2022 Section Cited CCR 87468.1	1 2 3 4 5 6 7	87468.1(2)Personal Rights:To be accorded safe, healthful and comfortable accommodations.... This requirement isn't met as evidenced by: Based on docs review & interviews, facility didn't comply w/section cited above w/	1 2 3 4 5 6 7	Licensee to ensure that facility care staff receives appropriated training and residents personal rights are being respected. Facility to submit proof of staff training for residents personal rights with staff names,
	8 9 10 11 12 13 14	at least 1 out 1 resident personal right which poses a potential health,safety, & personal rights risk for residents in care. Department learned that resident R4 was found tied to a chair around 21:00 hr. (see docs)	8 9 10 11 12 13 14	signatures, date, time, material used, trainer name & also signed by trainer by POC due date of 3/24/22 in order to clear this citation.
Type B 03/24/2022 Section Cited CCR 87464(d)	1 2 3 4 5 6 7	Basic Services(d)A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs ... This	1 2 3 4 5 6 7	Licensee to ensure that residents' needs are met all the time and staff is sufficient to meet the needs of the residents. Facility to submit self certification that there is sufficient staff to meet the needs of residents in care & plan
	8 9 10 11 12 13 14	requirement is not met as evidenced by:Based on interviews, records review,& obs, licensee didn't comply w/section cited above within the memory care residents needs & alarm system which poses a risk to their health and safety. (see records)	8 9 10 11 12 13 14	on how facility will ensure qualified carestaff is sufficient, and that alarm system will be answered.In addition,plan on how facility uses & checks motion sensors in memory care by POC date of 3/24/22.

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: 03/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20210824114946

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/10/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/24/2022 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	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 obs, records review & interviews,the	1 2 3 4 5 6 7	Facility agrees to ensure that qualified & sufficient staff will care for residents' according to their needs. Facility to provide Department with a plan on how facility will ensure that residents will have the qualified carestaff
	8 9 10 11 12 13 14	licensee didn't comply w/section cited above in 1out1 residential care facility which poses a potential health & safety risk to persons in care.Department learned that alarm system isn'tbeing answered in a timely matter & facility has 4 caregivers at AM & PM shift for 33 residents w/ 8 being 2 people assist, and 33 needing assistance w/ daily living.	8 9 10 11 12 13 14	to care for them, how motion sensors work & will be responded to in MC, and how facility will ensure alarms will be answered in AL and MC by POC date of 3/25/2022. (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.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 03/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022

LIC9099 (FAS) - (06/04)

Page: 8 of 9

Control Number 21-AS-20210824114946

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/10/2022

NARRATIVE

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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 12/14/21 through 3/10/22 - Title 22 Regulations # 87411(a)

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 12/14/21 through 3/10/22 - Title 22 Regulations # 87468.1

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 12/14/21 through 3/10/22 - Title 22 Regulations # 87464(d)

*****Total Civil Penalties issued today in the amount of $750.00

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. Appeal of Rights Given.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022

LIC9099 (FAS) - (06/04)

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