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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 12:16:26 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
12/16/2021 and conducted by Evaluator Carla Fernandes-Goes
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20211216130533
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:
11:38 AM
MET WITH:Kathleen Olson - Acting EDTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Facility did not follow resident's care plan.

Facility staff were not adequately trained to care for resident.

Staff did not safeguard residents' personal property.
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 12/22/2021, LPA Fernandes-Goes toured the facility; conducted interviews; acquired documentation; and made observations of the facility. During tour of the facility with Annemarie Domizio – former Executive Director on 12/22/21, 2/7/22, and 4/6/22, interviews with complainant, POA (Power of Attorney), Home Health (HH), and staff on 12/20 & 12/22/21 and 2/7/22; and documentation review, Department learned that resident R1 care plan dated 9/29/2021 states under “Compression Hose” facility to “assist with applying and removing compression leg wraps daily…trained care staff to place black stockings…”
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 7
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
12/16/2021 and conducted by Evaluator Carla Fernandes-Goes
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20211216130533

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:
11:38 AM
MET WITH:Kathleen Olson - Acting EDTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Facility staff did not adequately supervise resident resulting in a fall.

Resident was financially exploited while in 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 12/22/2021, LPA Fernandes-Goes toured the facility; conducted interviews; acquired documentation; and made observations of the facility. During tour of the facility with Annemarie Domizio – former Executive Director on 12/22/21, 2/7/22, and 4/6/22, interviews with complainant, POA (Power of Attorney), Home Health (HH), and staff on 12/20 & 12/22/21 and 2/7/22; and documentation review, Department learned that resident R1 had “fallen within the past year and requires a fall management program”; “Resident observation and assistance to attend meals and activities of choice”; “Requires schedule for toileting and assistance to and from the bathroom”; (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: 3 of 7
Control Number 21-AS-20211216130533
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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“Resident can be at risk for falls if she is slipping from her chair or if she tries to stand on her own. Please encourage to wait for a caregiver to arrive to help with transfers.” as stated on care plan dated 9/29/2021. Physical Therapy (PT) was in place and orders to “stand every 2 hours for pressure relief” as well as “walk with assistance… from apartment to dining and activities.” Per Resident Care Notes resident had a fall on 11/1/2021 & 9/10/2021 – no incident report submitted to the Department due to no injury according with documentation. According to staff notes on 11/1/2021 residents' fall was “notified by another resident. Resident R1 was … laying on bathroom floor hitting R1’s head. 911 was called… POA refused to transport. Resident R1 stated that resident wheeled her to bathroom. Resident R1 transferred unassisted lost balance.”, However, based on LPAs interviews and record review there was no information obtained or provided that R1 requested assistance from staff prior to fall. Department reviewed 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. At this time Department is not able to prove or disprove allegation “Facility staff didn’t adequately supervise resident resulting in a fall.”

POA during admission on 11/3/2020 signed up an agreement to participate in the “incontinence Management Program”. Facility program provides incontinence supplies on a monthly basis and/or as needed. LPA interview staff S3 who stated that during 2021 caregivers in memory care were responsible to provide an order for each resident under the program according with their needs. At the time resident R1 moved out, POA observed an “excess of (incontinence) supplies” that had been charged in a monthly ledger under “Personal Care Program” without itemization. Facility doesn’t buy back supplies and resident R1 kept incontinence supplies that were already purchased. Department based on documentation wasn’t able to prove or disprove that “Resident was financially exploited while in care.” therefore allegation is unsubstantiated.

A finding that the complaint allegations of "Facility staff did not adequately supervise resident resulting in a fall.” and “Resident was financially exploited while in care.” 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: 4 of 7
Control Number 21-AS-20211216130533
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, resident R1’s notes under “Outside Provider Communication” on file at facility has HH nurse on 10/28; 11/1; 11/5; and 11/10/21 stating that “staff is not applying the Circaid correctly and email from facility staff to POA dated 11/12/21 states “…’Resident R1’ has been having agency staff members assisting her.”(see staff training below) – (see copies, LIC 809-D) In addition, Department requested HH plan of care for resident R1 and learned on 5/11/2022 that resident has no Home Health plan of care on file. (see case management 5/26/2022) Based on documentation on file, Department was able to prove that facility wasn’t following resident’s R1 care plan by allowing staff not properly trained to care for the needs of resident R1.

During complaint investigation, agency staff members working at facility had no CPR, 1st Aid, or any other required training on file. In addition, 2 out of 2 facility staff reviewed files do not have all training hours required by Health & Safety Code (H&S) with S1 hired on 9/30/2020 total hours of 35 and S2 hired as caregiver on 1/9/2021 total hours of 13.75. H&S Code requires 40 hours of training with 20 hours to be completed before working independently with residents and 20 hours within the first four weeks of employment. Business Director Juan Ferrel stated that an emailed had been sent to agencies providing facility with staff on 2/7/2022 requesting proof for training. (see copies, confidential name list, LIC 809-D) In regard to “Facility staff were not adequately trained to care for resident.”, Department was able to prove allegation.

Regarding allegation “Staff did not safeguard residents' personal property.”, resident R1’s admission on 11/3/2020 contain form LIC 621 Client/Resident Personal Property and Valuables with specified resident’s belongs. Per complainant, due to COVID “facility requested through a phone call a table and chair because of quarantine” and other items were purchased which are missing. During investigation, Department learned that staff emailed POA on 11/12/2021 stating that “’med tech’ also notified ‘staff’ was unable to find the black stocking (stockings needed for Circaid application). HH Nurse also stated on Outside Provider Communication notes of 11/1/21 that “Upon arrival the circaid was not applied correctly; wrong lining, no other circaid for lower leg…. I will order another pair of circaids…”. Complainant also stated that chair bought to facility due to quarantine is missing. Emails between POA and facility staff state “… I will look around for it today”. Facility was not able to find chair or Circaid that belonged to resident R1. Based on investigation, Department is able to prove that resident R1’s personal property wasn’t safeguard. (see copies, LIC 809-D)


Continued LIC 9099-C
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: 5 of 7
Control Number 21-AS-20211216130533
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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According with complaint allegations “Facility did not follow resident's care plan.”; “Facility staff were not adequately trained to care for resident.”; “Staff did not safeguard residents' personal property.” 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 2/7/2022 through 5/26/2022 - Health & Safety Code 1669.625(b)

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

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 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: 2 of 7
Control Number 21-AS-20211216130533
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
87465(a)(2)
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Incidental Medical and Dental Care. This requiment is not met as evidenced by:Based on interviews,records review,facility didn't comply w/section cited above within 1 out of 1 resident care needs which poses a risk to
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Facility to ensure that resident's needs are met accordingly to doctor's orders and plan of care in place from facility and outside medical agency providers and sufficient qualified staff. Facility agrees to submit Department
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their health and safety.Resident R1 care plan dated 9/29/2021 states under “Compression Hose” that staff is to apply, however;outside provider notes state that facility is not applying properly even after staff training. (see records)
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a plan on how they will ensure that residents' services will be met as needed by POC date 6/9/2022.
Type B
06/09/2022
Section Cited
CCR
87217(b)
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Safeguards for Resident Cash, Personal Property, & Valuables. This requiment is not met as evidenced by:Based on interviews,records review,facility didn't comply w/section cited above within 1 out of 1 resident
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Facility to ensure the safeguard of residents' personal propery. Facility to ensure that all residents have a signed form signed and updated for Safeguards for Resident Property and sumbit to Department a self
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property which poses a risk to their health,safety, and personal rights of residents in care. Resident R1 had a chair and Circaid that per facility staff, facility wasn't able to find. (see copy of docs)
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certification that residents' will have their property safeguard at facility by POC date of 6/9/2022.
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: 7 of 7
Control Number 21-AS-20211216130533
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
HSC
1669.625(b)
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Staff training; legislative findings.This requirement is not met as evidenced by:Based on record review & interviews, licensee did not comply w/the section cited above in 2 out of 2 caregiver staff in addition to
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Facility agrees to ensure that all staff have appropriated training on file with day, time, amount of training hours, etc. Facility to review staff files and provide Department with an LIC 9098 self certification that caregivers
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agency staff which poses a potential health & safety risk to persons in care. Department learned during staff training review that S1, 2 & agency staff have no proof of all trainings required by H&S Code.
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including agency staff have all required training on file to be reviewed by the Department and plan on how to track training by POC date of 6/9/2022. (Civil Penalty due to 12 months repeat citation)
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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: 6 of 7