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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803904
Report Date: 10/21/2021
Date Signed: 11/09/2021 09:10:30 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 NOVATOFACILITY NUMBER:
216803904
ADMINISTRATOR:DOMIZIO, ANNEMARIEFACILITY TYPE:
740
ADDRESS:1465 S NOVATO BLVDTELEPHONE:
(628) 215-1200
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY:118CENSUS: 87DATE:
10/21/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Annemarie Domizio - Executive DirectorTIME COMPLETED:
04:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Fernandes-Goes conducted an unannounced case management and met with Silvia Anaya - Health & Wellness Director. The purpose of the case management visit was to obtain additional information regarding incident report submitted to the Department.

Department learned that on 10/4/2021 resident R1 left the facility unassisted at 2:30 PM and didn't come back until around 4 PM. Resident R1's physician's report dated 3/23/2021 states that resident has a diagnosis of dementia and not allowed to leave facility unassisted. (see copies, LIC 809-D)LPA asked questions and requested more information regarding facility procedures for residents not able to leave facility unassisted. Per staff, facility has residents were a roam alert that is supposed to go alarm if resident attempts to leave facility. In addition, concierge has a list of resident's names and room numbers when not allowed to leave facility. Staff receives training regarding residents and elopement. Concierge staff is available from 8 AM until 8 PM. Resident R1 came back to facility unharmed.

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: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/22/2021
Section Cited

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87705(b)(2)Care of Persons with Dementia - Safety measures to address behaviors such as wandering.This requirement isn't met as evidenced by:Based on interivew & records review the facility didn't comply w/this
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section for 1of1 residents which poses an immediate Health, Safety risk to residents in care. Resident R1 isn't allowed to leave facility unassisted; left at 2:30 AM on 10/4 and didn't came back until around 4 PM.
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date of training to be submitted to CCL by 11/04/21. Date for schedule staff training to be submitted to CCL by 10/22/21.

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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: 10/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2021
LIC809 (FAS) - (06/04)
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