216803904-5-27-2022-21-AS-BMOS-CEYR6Z-20220601124535

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216803904
Report Date: 05/26/2022
Date Signed: 05/27/2022 09:27:51 AM

Unsubstantiated

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
01/20/2022 and conducted by Evaluator Carla Fernandes-Goes

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20220120093526

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:	10:45 AM
MET WITH:	Kathleen Olson - Acting ED		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Staff are not following resident care plan
Staff are restraining resident

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 1/21/2022, LPA Sarangi opened complaint and requested documentation regarding resident R2. During tour of the facility with Annemarie Domizio – former Executive Director on 4/6/2022, and interviews with complainant, facility staff and Marin County Public Health on 2/2/2022 & 5/11/2022; and documentation review, Department learned that resident R2 is fall risk, under hospice care, living in Memory Care. Between 1/10/2022 and 1/25/2022 facility had 31 individuals in memory care in which 22 residents and 9 staff test positive for COVID. MCPH at the time allowed facility to conduct a reverse COVID quarantine due to the number of positive cases and memory care status. (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: 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-20220120093526

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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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. Facility was not to restrain non COVID residents and to ensure that they were properly placed under isolation. Based on complaint investigation, Department can’t prove or disprove that staff was restraining residents during COVID outbreak at facility. (see copies)

In regard to “Staff are not following resident care plan”, care plan dated 10/21/2021 states that resident is fall risk under fall management program due to “ walk quickly and often on R2’s toes”; “resident R2 does not use any assistive device to ambulate and can move very fast.” Resident R2 is under hospice care; had 1 fall in January 2022 with no injuries per resident’s notes. According with facility staff roster for December 2021 until January 2022, facility had 1 med tech in each shift, 5 caregivers AM & PM, and 2 NOC shift working together with med tech. Department is not able to prove or disprove that staff wasn’t following resident R2’s care plan at this time. (see copies)

A finding that the complaint allegations of " Staff are not following resident care plan.” And “Staff are restraining resident.” are 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: 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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