216804010-3-11-2022-21-AS-FSAI-CCESVH-20220311131246

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216804010
Report Date: 03/11/2022
Date Signed: 03/11/2022 01:12:54 PM

Document Has Been Signed on 03/11/2022 01:12 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	OAKMONT OF SAN RAFAEL		FACILITY NUMBER:	216804010
ADMINISTRATOR:	LIBHART, JILL		FACILITY TYPE:	740
ADDRESS:	1 LAS GALINAS AVE		TELEPHONE:	(628) 336-1400
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	126	CENSUS: 0	DATE:	03/11/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:09 AM
MET WITH:	Administrator, Jill Libhart Regional Vice President, Tamara Fernandez		TIME COMPLETED:	01:26 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), Farhaan Sarangi and Dina Alviso arrived at Oakmont of San Rafael for the purpose of conducting a Pre-Licensing inspection. LPAs were greeted at the door by two staff members. LPAS went through COVID-19 screening and log. LPAs were then led to the library by Administrator, Jill Libhart and Regional Vice President, Tamara Fernandez. Facility is approved for 126 non-ambulatory with 8 bedridden residents, effective January 13, 2022. The 8 bedridden residents are approved for the 1st and 2nd floor only. In addition, delayed egress was also approved on January 13, 2022. LPAs toured the facility with the Administrator and Regional Vice President, LPAs observed the facility to be clean and at a comfortable temperature with all exits free from obstruction. Perishable and Non-Perishable foods were observed in the kitchen fridge and freezer that was stored as per regulation. LPAs observed small couches and a kitchen prep area in the Memory Care Unit. LPAs observed the Memory Care unit on the first floor and two unit rooms that had a water temperature of 114.6 degrees and 111.2 degrees, showers are equipped with Non-slip floors and handrails by shower and toilets for residents use. LPAs also observed the egress door in the Memory Care unit that is properly operational and functioning at this time. While touring, LPAs observed the Memory Care Unit dining room with 8 tables and chairs. LPAs observed three emergency water containers that are stored in the garage. LPAs observed the movie theater with chairs and a popcorn machine which is also on the garage level. LPAs observed the outdoor seating area with two tables and chairs in the Memory Care Unit. LPAs observed the locked Memory Care Unit Medication Room along with the locked Laundry room and Housekeeping room that keeps the hazardous toxins locked and inaccessible to residents in care. LPAs toured the second floor and observed 109.4 degrees water temperature in a bedroom unit and Non-slip floors and handrails by shower and toilets for residents use. Fire extinguishers were last serviced on March 22, 2021 with an expected service date for March 22, 2022; Administrator stated that the company to service the fire extinguishers will be out on March 22, 2022. (Report continued on LIC 809C)

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022

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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: OAKMONT OF SAN RAFAEL	FACILITY NUMBER: 216804010
	VISIT DATE: 03/11/2022

NARRATIVE

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LPAs observed the activity room on the second floor with 6 small tables and 1 big table by the residential kitchen. LPAs observed the dining room also on the third floor with 12 tables and an outdoor dining patio. LPAs observed the kitchen where food will be served and a place where Special Diets will be in place. Emergency food was observed on the third floor. LPAs observed the temperature log where dishwasher, fridge and freezer are documented. LPAs observed the third floor that was equipped with a lounge/bar that will serve alcohol that will be open from 04:00 PM to 07:00 PM. Lounge/bar is locked outside of operating hours making it inaccessible to residents in care. The staff working at the lounge/bar are always on site serving residents and it will be maintained by facility staff. LPAs observed the exercise room and a salon where residents can have access to those amenities. Exercise room is left open at all times and the salon is observed to be locked during non-operating hours. LPAs requested and received a copy of Liability Insurance policy, but the policy will not go into effect until licensure.

In addition, LPAs advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. LPAs reviewed the Mitigation Plan with the facility during the Pre-Licensing inspection. Facility staff will obtain N95 Fit Testing, per administrator. Emergency Disaster plan was discussed with the Administrator. Portable Emergency Generator was brought on site during the Pre-Licensing inspection. LPAs observed the storage for Emergency supplies (First Aid Kit, batteries and supplies) on the first floor. A copy of the Administrators First Aid Certificate and CPR was fulfilled on January 23, 2022 and January 24, 2022. All staff will be trained in the Emergency Disaster training as required.

Component III was completed with the Administrator. Exit interview was conducted, and a copy of this report was given to the Administrator. LPAs will forward report to the assigned Application Analyst in our Department; The Application Analyst will notify the Applicant of the status of the application.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022

LIC809 (FAS) - (06/04)

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