216803904-8-27-2021-21-AS-CFGS-C6AMEQ-20210827093303

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216803904
Report Date: 08/26/2021
Date Signed: 08/27/2021 09:33:16 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: 82	DATE:	08/26/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	AnneMarie Domizio - Executive Director		TIME COMPLETED:	12:00 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	Licensing Program Analysts (LPAs) Fernandes-Goes conducted an unannounced Annual Required – 1 yr. & Non-Compliance Infection Control inspection to this facility and was welcome by Business Director Juan & AnneMarie Domizio – Executive Director. Facility has 82 residents with 33 in memory care. There are 9 residents under hospice care. Facility has activities for residents during the day. LPA arrived at the facility and had her temperature checked and logged into visitor’s binder. During facility tour on 8/26/2021 with ED AnneMarie, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 06/2020 at the time of the visit. Smoke Detectors & Carbon monoxide detector were operational during visit dated 6/18/21. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator wasn’t properly stored as per regulations on this day at the time of the visit. LPA observed small containers of dessert and 2 other trays with food that had the cover part off. (see picts, LIC 809-D, civil penalty) Menus are available and provided during meals. LPA observed that provisions are made for individuals with special dietary needs; facility keeps a variety of items on the menu, and facility has a board in the kitchen with a picture of the resident & a list of dietary needs. Food is available for residents any time of the day. There is a daily activity schedule for residents. Toxins are stored in a locked housekeeping room. There was a supply of cleaners, hygiene products and paper products available for residents. All bathrooms designated for residents at the facility were supplied with towels and hand soap dispensers when a private room. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. A sample tour of resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing. Facility understands that hot water temperatures must measure degrees F within Title 22 acceptable regulations of 105 to 120 degrees F. Continue LIC 809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021

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

LIC809 (FAS) - (06/04)

Page: 1 of 7

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: 08/26/2021

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
26
27
28
29
30
31
32

Infection Control:
Facility has submitted a mitigation program plan that has been approved. Posters have been placed at facility and entrance has table with hand sanitizer and other items designated for visitors and staff before coming into work. Facility has PPE supply stored in memory care storage, however; facility needs more N-95 masks and face shields/googles. Facility has hired staff and admitted new residents since COVID-19.

Continue LIC 809-C

Residents’ medications are stored and locked in medication room unless resident is able and allowed to dispense and store his/hers own medication. Facility has a 30-day supply of medication for residents. Residents aren’t wearing masks inside the facility, however; licensee/admin stated that they are able to wear masks when going on outings. All staff had masks on during this visit. Facility understands that unvaccinated staff must be tested once a week if PCR and vaccinated staff doesn’t need to be tested at this time if staff is able to show proof of vaccination which copy of vaccination card must be kept on facility file for staff at this time according with PIN 21-32-ASC & PIN 21-32.1-ASC: UPDATED FACILITY STAFF TESTING AND MASKING GUIDANCE FOR CORONAVIRUS DISEASE 2019 (COVID-19)

In addition, facility allowing visitors in the facility. Residents have also available telephone calls when contacting with family members and others. Staff had all PPE training required on file and are working towards obtaining N-95 fit testing.

LPAs advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Disaster Drills have been conducted quarterly with the last one being conducted on 8/5/2021.

In addition, LPA gather more information regarding incident reports and SOC 341s that were submitted to the Department by the facility.

Continue LIC 809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021

LIC809 (FAS) - (06/04)

Page: 2 of 7

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: 08/26/2021

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
26
27
28
29
30
31
32

There has been a change of administrator in the facility Department is requesting the following documentation to be submitted by September 2, 2021:

LIC 200 (original - must be mailed or delivered to the Regional Office)
LIC 308 Designation of Facility responsibility (designation of who is the administrator)
Administrator Certificate
Administrator Resume
LIC 500 Personnel Report
LIC 501 Personnel Record
LIC 508 Criminal Record Statement
Copy of Board of Directors' Resolution meeting minutes signed (required for all corporations)

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 6/18/2021 through 8/26/2021 - Title 22 Regulations # 87555(b)(23).

*****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.

Department is requesting facility to update and submit the following documents to CCLD by 9/2/2021:

LIC 308 Designated
LIC 610 Emergency Disaster Plan
LIC 610E-S Supplemental Emergency Disaster Plan for RCFE
Copy of Certificate of Liability Insurance
Copy of Administrator Certificate

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021

LIC809 (FAS) - (06/04)

Page: 3 of 7

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: 08/26/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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 1 out of 1 refrigerator in main kitchen which poses/posed a potential health, safety or personal rights risk to persons in care. LPA toured the facility w/ ED and observed dessert containers and food trays not covered or with ceramic wrap/foil paper of the container. Food was cold and dry. (see picts)
	POC Due Date: 09/09/2021
	Plan of Correction
1 2 3 4	Facility to ensure that all food stored in refrigerators are properly stored at all times. Facility to review kitchen refrigerator dispose food of not good quality or properly stored. and ensure that staff understands why the need to proper store food. Facility submit LIC 9098 self-certification that food has been checked and staff understands this concept by POC date 9/9/21.(Civil P)

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: 08/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021

LIC809 (FAS) - (06/04)

Page: 4 of 7