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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216803904
Report Date: 05/26/2022
Date Signed: 05/26/2022 11:39:16 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
01/04/2022 and conducted by Evaluator Carla Fernandes-Goes
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20220104151227
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:
05/26/2022
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Kathleen Olson - Acting EDTIME COMPLETED:
11:38 AM
ALLEGATION(S):
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Personal Rights.
Staff not responding to assist in a timely manner.
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 6, 2022; LPA Fernandes-Goes opened the complaint allegations listed above and acquired documentation. Interviews of complainant, residents, family members, Marin County Public Health, & staff was conducted, and records were reviewed. Per interviews and records, facility had a COVID-19 outbreak between January and February 2022 with several staff and residents infected with the disease.
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, etc. (Continued LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 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)
Page: 1 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
01/04/2022 and conducted by Evaluator Carla Fernandes-Goes
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20220104151227

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: DATE:
05/26/2022
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:TIME COMPLETED:
11:38 AM
ALLEGATION(S):
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No one in charge after hours or on weekends.
Activity schedule not provided timely.
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.

According with conducted interviews; acquired documentation; and observations of the facility, Department learned that facility policy states that “There will be at least one administrator, facility manager, or designated substitute who is at least 21 years old on duty and on site 24 hrs per day.” with medication technician as part of designated person in charge. Facility has a medication technician in all facility shifts and facility staff records for November/December 2021 shows at least one medication technician on site.
Continued LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 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)
Page: 2 of 5
Control Number 21-AS-20220104151227
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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However, not all staff at facility during weekends and after hours might have knowledge of who is the designated person in charge when asked by residents and/or family members. Based on this, Department is not able to proof or disprove that facility has no one in charge after hours or on weekends.

In regard to “Activity schedule not provided timely.”, during facility visitation on 2/7/22 and 4/6/22, LPA was able to observe an updated activity calendar in common area of memory care, entrance of activity room by assisted living dining room and another copy by elevator. However; complainant stated that facility wasn’t updating activity calendar for two months. Based on interviews and observation, Department at this time is not able to proof or disprove that activity schedule wasn’t updated and or provided to residents' in a timely matter.

A finding that the complaint allegations of “No one in charge after hours or on weekends.” And “Activity schedule not provided timely.” 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 MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 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)
Page: 3 of 5
Control Number 21-AS-20220104151227
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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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.” 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. Dining room stayed open with assisted living conducting two meal shifts and memory care one shift without social distancing of 6 feet. 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. MCPH communicated concern of facility staff ability to follow guidance advised. (see copy of documentation, Complaint # 21-AS-20220114144757 – substantiated) Based on interviews and documentation reviewed, facility failed to ensure that resident’s personal rights were not violated.

Regarding allegation of “Staff not responding to assist in a timely manner.”, after records reviewed and interviews, Department learned that staff failed on responding to call system timely. Records show that between 12/9/21 and 12/15/21 staff took 11 to 36 min to respond 25% of call buttons for assisted living and 5% never had a response. (see LIC 9099-D, Civil Penalties)

According with complaint allegation "Personal Rights.”; “Staff not responding to assist in a timely manner.” 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.

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 4/26/2022 through 5/26/2022 - Title 22 Regulations # 87464(d)

*****Total Civil Penalties issued today in the amount of $250.00.

Appeal of Rights Given.The following deficiencies were observed (see LIC 9009D) 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 MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 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)
Page: 4 of 5
Control Number 21-AS-20220104151227
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
87464(d)
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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,facility shall be responsible meeting resident's needs. This requirement is not
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Licensee to ensure that residents' needs are met all the time & staff is sufficient to meet needs of the residents. Facility to verify and submit self certification that there is sufficient staff to meet the needs of residents in care,
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met as evidenced by:Based on interviews,records review,facility didn't comply w/section cited above within assisted living residents needs & alarm system which poses a risk to their health and safety. (see records)
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that they are qualified , and that alarm system is working & will be answered in a timely matter by POC date of 6/9/2022.(Civil Penalty - repeat citation within 12 months)
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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: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 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)
Page: 5 of 5