216803904-5-27-2022-21-AS-BMOS-CEYR4J-20220601124137

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216803904
Report Date: 05/26/2022
Date Signed: 05/27/2022 10:51:53 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
01/18/2022 and conducted by Evaluator Carla Fernandes-Goes

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20220118140647

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:	11:00 AM
MET WITH:	Kathleen Olson - Acting ED		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Staff do not assist resident with incontinence care.

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 the complaint investigation and requested documentation. LPA Fernandes-Goes visit facility on 4/6/2022 and requested other documentation for resident R3; additional documentation was requested. Upon documentation review and interview conducted on 3/26/2022, Department learned that resident R3 physician assessment dated 12/14/2021 states that resident needs assistance to care for own toileting needs and care plan supports assistance needed. Resident R3 had a visit to ER on 12/10/2021 with discharge to Hospice and discharge of severe septs UTI. (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-20220118140647

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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Facility former ED AnneMarie Domizio submitted “Incontinence Care Procedures” in which “staff checks off daily tasks on the ADL log”, however; facility only keep these "records for 30 days" per ED Kathleen Olson. In addition, Department reviewed facility staff roster for December 2021 according with facility schedule there was 1 med tech in each shift, 5 caregivers AM & PM, and 2 NOC shift working together with med tech. At this time, based on documentation review and interviews Department is not able to prove or disprove that staff wasn’t assisting resident R3 with incontinence care.

A finding that the complaint allegation of "Staff do not assist resident with incontinence care.” 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: 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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