216803904-6-18-2021-21-AS-CFGS-C44QTQ-20210618122731

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216803904
Report Date: 06/18/2021
Date Signed: 06/18/2021 03:01:38 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME:	OAKMONT OF NOVATO		FACILITY NUMBER:	216803904
ADMINISTRATOR:	CAVE, JEFF		FACILITY TYPE:	740
ADDRESS:	1465 S NOVATO BLVD		TELEPHONE:	(628) 215-1200
CITY:	NOVATO	STATE: CA	ZIP CODE:	94947
CAPACITY:	118	CENSUS: 93	DATE:	06/18/2021
TYPE OF VISIT:	Post Licensing	ANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Jeff Cave - Regional Executive Director Specialist		TIME COMPLETED:	12:27 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	License Program Analyst (LPA) Fernandes-Goes arrived announced to conduct a continuation post licensing & infection control required visit of the facility that occurred on 6/17/2021. LPA was welcomed by Juan Ferrel - Business Director; Jeff Cave arrived during this visit There is a total of 62 residents in assisted living, and 31 residents in memory care. There are 3 residents under Hospice care in Traditions - Memory Care. LPA toured the facility on 6/17/2021 at 9:10 AM and a sample of 10 resident's (assisted living & memory care) files were reviewed at 12:30 PM. As per LPAs observation, documentation review, and interviews conducted on 6/17/2021. Facility is being cited for the following: (please see LIC 809 dated 6/17/2021 for more information) * 3 out of 10 residents have no pre-assessments/pre-appraisals. * 2 out of 10 residents have an incomplete LIC 602 physician's assessment. * 3 out of 10 residents have unlocked medications in their bathroom which according to their LIC 602 – physician’s assessment aren’t “able to administer own prescription medications, able to administer own PRN medications, or able to store own medications.”; 2 out of 3 have a diagnostic of dementia. * Food in main and memory care/Traditions kitchen refrigerator were not properly stored. LPA observed a number of food items such as chicken, pasta, desserts, sauce, soups, and etc placed in the refrigerator without any lid or anything covering the food items. * Hot water temperature on 4 out of 10 resident's bathroom faucets were between 113.3 and 122.5 degrees F. On 6/17/2021, LPA had a report regarding this deficiencies signed by administrator/executive director at the facility.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: OAKMONT OF NOVATO	FACILITY NUMBER: 216803904
	VISIT DATE: 06/18/2021

NARRATIVE

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On 6/17/2021, LPA had a report regarding this deficiencies given and signed by administrator/executive director at the facility. In addition, on 6/17/2021 LPA discussed with Jeff Cave Regional Executive Director Specialist regarding observation during tour, files review, and response time and/or no response for egress doors in memory care and alert button on resident's bathrooms.

Facility Executive Director was also informed on 6/17/2021 that meeting has been schedule for July 02, 2021 at 1:30 PM to discuss areas of concern and non-compliance.

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.
There were no deficiencies cited at this time.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021

LIC809 (FAS) - (06/04)

Page: 2 of 10

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: OAKMONT OF NOVATO	FACILITY NUMBER: 216803904
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/18/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 4 out of 10 resident's bathroom faucets which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/19/2021
	Plan of Correction
1 2 3 4	Facility to ensure that hot water temperature stays within Title 22 Regulations of not less than 105 degree F and not more than 120 degree F. Facility adjusted hot water during the visit and is to submit a seven day hot water temperature log by POC date of 6/25/2021 in order to clear this citation.

Type A

Section Cited

CCR

87705(f)(2)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in 2 out of 10 residents and 1 more resident without had unlocked medications in their bathroom (see pics) and a physicians assessment not allowing resident to store or dispense meds which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/19/2021
	Plan of Correction
1 2 3 4	Facility to ensure that medications are inaccessible at all times for residents who are not allowed to store and/or dispense meds. Facility to remove and lock all items specified above for residents R4,R5,R6 by POC due date of 6/19/2021 and check on other residents throrugh out of the facility Facility agrees to submit LIC 9098 self-certification that facility is compliant with this regulation.

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 Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: OAKMONT OF NOVATO	FACILITY NUMBER: 216803904
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/18/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87506(b)(15)

Resident Records

(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation & record review, the licensee did not comply with the section cited above in 3 out of 10 residents pre-admission appraisal which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/02/2021
	Plan of Correction
1 2 3 4	Facility agree to submit a written plan for future compliance in how the following areas are performed; pre-appraisals, re-appraisals,and if change of condition is observed . In addition, appraisal for R1, R3, and R7 with all signatures and written plan to be submitted to CCL by POC date of 7/2/2021.

Type B

Section Cited

CCR

87555(b)(23)

General Food Service Requirements

(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 2 out of 2 kitchen refrigerator had several food items inside uncovered containers (pics on file) which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/02/2021
	Plan of Correction
1 2 3 4	Facility to ensure that all staff that is required to work at either facility kitchen and/or handle food will be trained on how to ensure food safety and good food storage practices by POC due date of 7/2/2021. Facility to submit as proof of training with staff names, signatures, date, time, topic covered, and name of trainer.

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 Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021

LIC809 (FAS) - (06/04)

Page: 4 of 10

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: OAKMONT OF NOVATO	FACILITY NUMBER: 216803904
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/18/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(c)

87458(c) Medical Assessment;The licensee shall obtain an updated medical assessment when required by the Department. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation & record review, the licensee did not comply with the section cited above in 2 out of 10 residents have an incomplete medical assessment (LIC 602) on file which poses/posed a potential health, safety or personal rights risk to persons in care. Residents R2 & R3 had a medical assessment on file that had several pages incomplete by physician. (see copies)
	POC Due Date: 07/02/2021
	Plan of Correction
1 2 3 4	Facility to ensure that all medical assessments are complete, date, and signed by the doctor. Facility to request a complete medical assessment for resident R2 & R3 and submit a copy of medical assessment to the Department by due date of 7/2/2021 is order to clear this citation.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021

LIC809 (FAS) - (06/04)

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