216803904-7-8-2021-21-AS-CFGS-C4QM6N-20210708092013

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216803904
Report Date: 07/02/2021
Date Signed: 07/08/2021 09:20:26 AM

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: 0	DATE:	07/02/2021
TYPE OF VISIT:	Office	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Tamara Fernandez - VP of Operations		TIME COMPLETED:	02:45 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	Regional Manager Carla Martinez, Licensing Program Manager Bethany Moellers, Licensing Program Analyst Carla Fernandes-Goes met with Corinne Shell – Regional Director of Operations, Mandy Curtis – Sr. VP of Clinical, Tamara Fernandez – VP of Operations, Joel Goldman – Legal Counsel. This meeting was conducted virtually due to COVID-19. This Compliance Plan Conference is being conducted to discuss concerns identified by the Licensing Agency in regard to the operation of this facility including but not limited to: Complaint investigation that has been substantiated for prohibited condition and timely medical attention. Other concerns that have been observed during a post-licensing visit are: Ø Medications: Facility had residents with unlocked medications in their possession who were not allowed to store and/or dispense medications according to physician's reports on file. Ø Prohibited Conditions: Facility retained a resident with a prohibited condition Ø Timely Medical Attention: Facility failed to seek timely medical attention. Ø Medical Assessments: Facility failed to ensure that resident's medical assessments/physician's report is complete as required. Ø Resident Records: Facility wasn't able to provide CCLD with pre-appraisals for resident's files that were reviewed. Ø Staffing: Facility memory care didn't have adequate number of direct care staff to support each resident's physical, social, emotional, safety and health care needs. Ø Facility Food Services: The Regional Office will re-review progress made on Non-Compliance Plan of 2 years.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021

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: 07/02/2021

NARRATIVE

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CCL has provided copies of the following Regulations: Title 22 Regulations #87465 Incidental Medical & Dental Care; #87705 Care of Persons w/Dementia; #87615 Prohibited Health Conditions; # 87458 Medical Assessment; # 87506 Resident Records; #87555 General Food Service.

Licensee agreed to do the following in order to bring the facility into compliance no later than the following dates:

1. Medications: Facility will ensure that ALL residents that are not allowed to store and/or dispense medications will have their medications locked at all times. Facility to review residents rooms/bathrooms & medical assessments to take appropriate measures. Please submit your updated plan by July 12, 2021

2. Medication Errors: Facility will ensure that medications will be dispensed according to doctor's orders, and staff will follow appropriate procedures when dispensing meds to ensure residents' health & safety, please submit your updated plan by July 12, 2021

3. Prohibited Conditions: Facility will ensure that residents with a prohibited condition will not be retained unless an exception is approved by CCLD. Facility has submitted a plan of correction on June 21,2021 which is under review
4. Timely Medical Attention: Facility will ensure to seek timely medical attention for residents in care. Facility has submitted a plan of correction on June 21, 2021 which is under review

4. Medical Assessments: Facility will ensure that resident's medical assessments/physician's report is fully complete as required. Facility to review all residents medical assessments and submit your updated plan by July 12, 2021

5. Resident Records: Facility will ensure that residents' files have all required documents on file and ready to be reviewed by CCLD. Facility to have all residents' files complete w/ appropriate signatures by July 12, 2021. Please update any changes to plan and submit by July 12, 2021

6. Staffing: Facility memory care will have adequate number of direct care staff to support each resident's physical, social, emotional, safety and health care needs. Facility to submit plan related to staffing for each shift by July 12, 2021 – (Please ensure that when call alert and activities are being provided; maybe an activity calendar and list of call alerts that are answered)

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021

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
	VISIT DATE: 07/02/2021

NARRATIVE

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7. Facility Food Services: Facility will ensure that perishable foods are stored in covered containers. Facility to submit proof of kitchen staff training by certified staff on food handling & storing regarding this regulation by July 12, 2021 - (copy of Reg #87555 General Food Service provided)

The licensee was informed that additional civil penalties are under review by the Department per Health and Safety Code 1569.49 (f) due to substantiated complaint # 21-AS-20210310171803.

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: 07/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021

LIC809 (FAS) - (06/04)

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