216803904-5-26-2022-21-AS-BMOS-CEYR2X-20220601123905

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216803904
Report Date: 05/26/2022
Date Signed: 05/26/2022 04:04:55 PM

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
01/14/2022 and conducted by Evaluator Carla Fernandes-Goes

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20220114144757

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: 81	DATE:	05/26/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Kathleen Olson - Acting ED		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

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Facility is not following proper protocol for COVID-19

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 - Acting ED.

On January 21, 2022; LPA Sarangi opened the complaint allegation listed above and acquired documentation. There were several complainants under this allegation. Department has learned per records reviewed and interviews of complainants, staff, Marin County Public Health (MCPH), residents, and responsible parties that facility had an COVID-19 outbreak between January and February 2022. During this time there were several residents and staff that became infected with the disease.

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: 05/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022

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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Control Number 21-AS-20220114144757

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: 05/26/2022

NARRATIVE

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MCPH guidelines for facilities during an outbreak were to close dining room, no visitors allowed unless under hospice due to end of life, residents with symptoms and/or exposed to COVID to be isolated, COVID positive to be placed under quarantine, and etc. In addition, PINs for COVID-19 states that “If there are differing requirements between the most current CDC, CDPH, CDSS, CDDS, Cal/OSHA, and local health department guidance or health orders, licensees should follow the strictest requirements.” Outbreak started in assisted living and facility allowed residents from assisted living to visit residents' in memory care, outside visitors were allowed into the facility including memory care with a final count of 22 COVID-19 positive cases of residents'. Dinning room stayed open with assisted living conducting two meal shifts and memory care one shift without social distancing of 6 feet. Testing was being conducted weekly as required, however; residents in assisted living would stand in line without social distancing and/or masks waiting for their turn to be tested. Residents that were not COVID positive were requested to stay in their bedrooms and quarantine for their health and safety. However, MCPH communicated concern of staff training regarding isolation vs quarantine and staffs ability to follow guidance advised. (see copy of documentation, LIC 809-D) Based on interviews and documentation reviewed, facility didn’t follow proper COVID-19 protocol.

According with complaint allegation "Facility is not following proper protocol for COVID-19.” there was 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.

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: 05/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20220114144757

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: 05/26/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/09/2022 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1(a)(2) Personal Rights of Residents in All Facilities. This requirement was not met as evidenced by: Based on record review & interviews, facility did not comply w/ Marin County Public Health & Department	1 2 3 4 5 6 7	Licensee agreed to review COVID Mitigation Plan Report (MPR) in place and submit a reviewed to be implemented COVID-19 MPR w/ specify info on how will facility conduct testing, quarantine for MC & AL
	8 9 10 11 12 13 14	Social Services guidelines and requirements, which poses a potential health, safety, and personal rights risk to residents in care. (see interviews and record reviews)	8 9 10 11 12 13 14	w/ plan set up, name of lead infection control contact MCPH & DSS, staff N-95 fit testing, staff training,& etc by 6/9/2022 to the CCLD to be reviewed. Licensee shall email report to CCLASCPSantaRosaRO@dss.ca.gov
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	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: 05/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022

LIC9099 (FAS) - (06/04)

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