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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216803904
Report Date: 12/22/2022
Date Signed: 12/22/2022 04:09:58 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
06/24/2022 and conducted by Evaluator Victoria Bertozzi
COMPLAINT CONTROL NUMBER: 21-AS-20220624083702
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:0CENSUS: 0DATE:
12/22/2022
UNANNOUNCEDTIME BEGAN:
11:57 AM
MET WITH:Business Office Manager, Tristan AmariTIME COMPLETED:
04:20 PM
ALLEGATION(S):
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Neglect/Lack of Supervision, resident suffered a fall resulting in injury and medical attention was not sought timely
Facility not following resident’s care plan
Resident is unable to use medical device.
INVESTIGATION FINDINGS:
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The Department conducted a complaint investigation regarding the allegations listed above. Licensing Program Analyst Bertozzi and Nakagawa arrived unannounced for the purpose of delivering findings and met with Business Office Manager, Tristan Amari.

Department learned that resident, R1 was admitted to assisted living in October 2020 and subsequently moved into memory care in July 2021. R1’s LIC 602 (physician’s assessment) dated June 16, 2022, states R1 has cognitive concerns, wandering behavior and sleep apnea but was able to communicate needs. R1 was able, with assistance, to do the following: bathe self, dress/groom, feed, and care for own toileting needs. R1’s Care Plan documented R1 was a fall risk. On June 1, 2022, R1 had an unwitnessed fall, R1 fell in their closet, when staff found R1 they were assessed for injury, while no injury was noted, staff did contact R1’s physician the next day to check for a possible UTI, staff interviewed stated R1 was “off balance, agitated, very confused, needing two staff to transfer and it was observed R1’s left leg was dragging”.

Continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022
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
SANTA ROSA RO, 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
06/24/2022 and conducted by Evaluator Victoria Bertozzi
COMPLAINT CONTROL NUMBER: 21-AS-20220624083702

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:0CENSUS: 0DATE:
12/22/2022
UNANNOUNCEDTIME BEGAN:
11:57 AM
MET WITH:Business Office Manager, Tristan AmariTIME COMPLETED:
04:20 PM
ALLEGATION(S):
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Staff not ensuring that resident is properly clothed
INVESTIGATION FINDINGS:
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The Department conducted a complaint investigation regarding the allegations listed above. Licensing Program Analyst Bertozzi arrived unannounced for the purpose of delivering findings and met with Business Office Manager, Tristan Amari.

Department has learned that resident’s R1 Care Plan dated 12/15/21 states R1 “requires stand by assistance with set up and performance of grooming tasks (28 points); 3 to 4x/week showers (10 points); requires stand by assistance with dressing and undressing 2x/day (31 points)” and care plan 6/13/2022 states “requires stand by assistance with s/set up and performance of grooming tasks (28 points); 1 to 2x/week showers (13 points); requires hands on assistance with dressing and undressing 2x/day (37 points). Department has learned that resident R1 was found with same clothes by family member when visiting consecutive days. Facility staff stated, “that residents are changed in the morning and/or if they have an accident. They are not forced to change.” And has no changing record logs. During visit on 7/21/2022, LPA observed resident R1 seating in the dining room with another resident.

Continued on LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022
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-20220624083702
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: OAKMONT OF NOVATO
FACILITY NUMBER: 216803904
VISIT DATE: 12/22/2022
NARRATIVE
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Continued from LIC9099A

Resident R1 was fully clothed – on day clothes which looked clean. In regard to staff not ensuring that resident is properly clothed during the night, at this time Department can’t prove or disprove that it has occurred.

A finding that the complaint allegations of “Facility staff not ensuring that resident is properly clothed during the night.” 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: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20220624083702
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: OAKMONT OF NOVATO
FACILITY NUMBER: 216803904
VISIT DATE: 12/22/2022
NARRATIVE
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Continued from LIC9099

Although staff did not observe injury after the fall, staff did observe a change in condition on June 2, 2022, staff failed to have R1 seen by a physician and update their Care Plan. Subsequently, on June 13, 2022, R1 had a seizure and was taken to the ER and later transferred to a local hospital where the physician attributed the seizure to “old blood that pooled after a fall, visible on a CT scan”. Facility placed resident on a fall management program on or around January 2022, which included ensuring R1’s bedroom was decluttered and hazard free. When staff were interviewed, they were unaware of the fall management program.

Additionally, R1 was unable to use their medical device and facility failed to follow resident’s care plan. R1’s care plan required staff assist resident with their (CPAP) breathing machine and breathing treatments as follows. Care Plan dated December 15, 2021 as well as updated Care plan dated 6/13/2022 state; R1 requires staff stand-by assistance with-set up and performance of grooming tasks (28 points); 1 to 2x/week showers (13 points); requires hands on assistance with dressing and undressing 2x/day (37 points); requires a fall management program due to fall within the past year (16 points); breathing treatments – resident requires staff observation and assistance 1 to 2 times per day (15 points). Additional instructions specific to Breathing Treatments states; “Resident requires staff observation and assistance 1 to 2 times per day.” With the following: “Assist resident with setting up CPAP machine in the evening around 8:30 – 9pm. This includes filling the cage with water, hooking the hose up, and turning it on. Remove CPAP from apartment and clean during the day – store in med room. Resident ‘R1’ has tendency to hide pieces if left in apartment. The PM shift will bring to ‘resident R1’ around bedtime and assist with set up. Overnight shift will need to check in and see that ‘R1’ is still wearing CPAP during the night.” Between June 3, 2022, and June 21, 2022, resident did not receive their breathing treatment 14 times due to missing parts on the machine. Based on documentation reviewed, facility failed to follow care plan and follow doctor’s orders on how to assist resident R1 use of medical device as it was agreed upon and monthly charged .

Based on LPAs' observations and interviews which were conducted and documentation reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

Deficiencies 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 rights given.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20220624083702
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: OAKMONT OF NOVATO
FACILITY NUMBER: 216803904
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/09/2023
Section Cited
CCR
87465(a)(2)
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87465 (a)(2) Incidental Medical and Dental Care - The licensee shall provide assistance in meeting necessary medical and dental needs...Licensee did not meet this requirement as evidenced by: Based on evidence obtained during investigation, facility staff failed to seek timely medical after an observed change in condition possibly due to
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Facility will ensure all staff are trained on facilities protocols for unwitnessed falls and change of condition by POC 1/9/2023 and submit proof to CCL by POC due date.
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a fall the day prior. R1 had an unwitnessed fall on 6/1/22, the next day staff observed resident to be “off balance, agitated, very confused, needing two staff to transfer and it was observed R1’s left leg was dragging”. Staff failed to have R1 seen by a physician.
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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: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5