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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216803904
Report Date: 04/26/2022
Date Signed: 04/26/2022 11:27:20 AM

Substantiated


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
02/25/2022 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20220225125751
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:
04/26/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Kathleen OlsonTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility staff mismanaged resident's medications
Resident fell multiple times while in care.
Facility staff did not seek resident timely medical attention.
Facility staff did not follow resident's care plan.
INVESTIGATION FINDINGS:
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Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. LPA met with Regional Op. Specialist and discussed the findings. Complainant alleges that the facility did not administer medications as ordered by physician; that R1 fell many times in care and that R1's care plan of 07/01/21 specifically directs the development of fall prevention plan for R1 which did not occur until 03/18/22; That physician ordered medical tests on or about November 17, 2021 but were not provided until mid February 2022. This Department has verified these allegations in that: Facility records reviewed as well as statements taken and site visits made confirm that dosage for Med #1 was ordered 11/17/20 but not administered until 02/12/21; R1's written fall evaluation/plan was not developed until 3/18/22 but is required by R1's care plan of 07/1/21 due to history of falling; Substantial lab and medical testing was ordered for R1 in November 2021 but 2 of 3 procedures not provided until 02/16 and 02/22/22. Based upon the records reviewed, statements taken and site visits made, the preponderance of evidence standard has been met. Therefore, the allegations are SUBSTANTIATED.
*****Continued on second page*********
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022
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 5
Control Number 21-AS-20220225125751
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: 04/26/2022
NARRATIVE
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The following deficiencies were observed (see LIC 9099D) 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.

Copy of report left at facility.

SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20220225125751
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: 04/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/29/2022
Section Cited
CCR
87465(c)(2)
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87465(c)(2) Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions. ***Based upon documents reviewed, this requirement not met as evidenced by: Dosage for Med#1 ordered in November 2020 was not administered as prescribed until February
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Administration to submit written plan which addresses how facility will ensure compliance with 87465(c)(2) going forward. To be submitted to CCL by POC date in order to clear the deficiency.

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2021. This posed an immediate risk to health of R1.
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Type A
04/29/2022
Section Cited
CCR
87465(a)(1)
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87465(a)(1) Incidental Medical and Dental Care. The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. ***Based upon records reviewed and statements taken, this requirement has not been met as evidenced by: Medical tests ordered for R1 in November 2021
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Administration to submit written plan which addresses how facility will ensure compliance with 87465(a)(1) going forward. To be submitted to CCL by POC date in order to clear the deficiency.

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were not made until 2/16 and 2/22/22. This posed an immediate risk to the health of R1.
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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: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20220225125751
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: 04/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/10/2022
Section Cited
CCR
87464(d)
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87464(d) Basic Services. …the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal …Based upon records reviewed and statement taken, this requirement not met as evidenced by: R1 has substantial fall
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Administration to submit written plan which addresses how facility will ensure compliance with 87464(d) going forward. To be submitted to CCL by POC date in order to clear the deficiency.

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history while in care whose care plan of 07/01/2021 requires a fall evaluation/plan which was not provided until 03/18/2022. This posed a potential risk to the health and safety of R1.
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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: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
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
02/25/2022 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20220225125751

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:
04/26/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Kathleen OlsonTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility staff did not ensure that resident was adequately hydrated.
Facility staff did not ensure that resident was adequately fed.
Facility staff did not adequately communicate with resident's responsible parties.
Resident's medical equipment had missing pieces;
Facility staff did not assist resident with using the breathing machine.
Facility staff did not ensure that resident had a change of clothing.
INVESTIGATION FINDINGS:
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Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. LPA met with Kathleen Olson and discussed the findings. Complainant alleges the above listed allegations which were investigated by conducting interviews, site visits, and records reviews. The following determinations are made: Facility offers nutritious foods for residents in adequate amounts, water is made available to residents frequently, R1 states a dislike of drinking water and has no complaints regarding food or hydration, records are not kept on food and water intake unless ordered by Physician; Records and staff statements indicate that R1 was assisted with breathing machinery and that R1 would often hide parts of the breathing machine in room or elsewhere; On 09/16/2020 Responsible Person for R1 signed a waiver to have R1’s personal property inventoried by the facility and no record of R1’s clothing is on record; Facility Incident Reports suggest that all serious incidents were timely reported as required by 87211 and investigation revealed no serious incidents went unreported. Although the allegations may be valid, based upon records and statements, there is not a preponderance of evidence to prove or disprove the allegations. Therefore, the allegations are UNSUBSTANTIATED.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 5