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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216804010
Report Date: 06/24/2022
Date Signed: 06/24/2022 01:13:29 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/29/2022 and conducted by Evaluator Farhaan Sarangi
COMPLAINT CONTROL NUMBER: 21-AS-20220429165154
FACILITY NAME:OAKMONT OF SAN RAFAELFACILITY NUMBER:
216804010
ADMINISTRATOR:LIBHART, JILLFACILITY TYPE:
740
ADDRESS:1 LAS GALINAS AVETELEPHONE:
(628) 336-1400
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:126CENSUS: 54DATE:
06/24/2022
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Resident Relations Director, Linda NguyenTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff not following Covid-19 masking protocols.
Medication's were not administered to resident according to their physician's instructions.
Resident's medication documentation was not accurate.
Resident's care plan was not adhered to when facility failed to respond to Call Bell in a timely manner.
Unqualified staff.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Oakmont of San Rafael for the purpose of delivering complaint findings on a complaint that was initiated on April 29, 2022. LPA was greeted at the door by Concierge, Raymond, and granted access into the facility.

Complaint alleges that Staff are not following Covid-19 masking protocols. During the course of the investigation, LPA interviewed a staff member, and learned that facility staff do not wear masks properly. In addition, the facility staff have to be reminded to wear the masks properly by another staff member (See LIC 9099D).

Complaint alleges that Medications were not administered to resident according to their physicians’ instructions and Resident's medication documentation was not accurate. During the course of the investigation, LPA learned via an observation of the Medication Assessment Record (MAR) for former resident, and an interview with a staff member that a medication was missed on April 17, 2022.

(Report continued on LIC 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 21-AS-20220429165154
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/24/2022
NARRATIVE
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LPA reviewed the Medication List and determined that the medication that was missed was supposed to be administered on certain days including the day of April 17, 2022. Facility failed to administer the medication based off of physician’s instructions (See LIC 9099D). During the Document Review of the Medication Assessment Record (MAR), LPA observed the medication documentation was not accurate due to the facility staff missing a medication pass and not properly documenting the medication that was missed on April 17, 2022. In addition, the staff member that missed the medication pass did not communicate to upper level management regarding the missed medication for that day nor document in the MAR the missed medication (See LIC 9099D).

Complaint alleges that Resident's care plan was not adhered to when facility failed to respond to Call Bell in a timely manner. During the course of the investigation, LPA reviewed facility records and learned that on April 17, 2022 the resident call bell was not responded to when pressed. The resident had to wait 1 hour and 40 minutes before a staff member responded to that call bell (See LIC 9099D).

Complaint alleges that there are unqualified staff at the facility. During the course of the investigation, LPA conducted interviews and reviewed facility records and learned that 9 staff members have not had the required training hours as specified in regulation (See LIC 9099D).

The following deficiencies were observed (see LIC 9099D) 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 to the Resident Relations Director, Linda Nguyen.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 21-AS-20220429165154
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/27/2022
Section Cited
CCR
87307(d)(3)(B)
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87307(d)(3)(B): Facility failed to protect the personal rights of residents in care to receive safe and healthful accommodations and engaged in conduct inimical to the health, welfare, and safety of residents in care, in that staff members failed to properly wear face coverings while providing care and supervision to residents in care*,
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Licensee shall conduct PPE training and create a summary on how future compliance will be met. In addition, Licensee shall submit a staff training sign-in sheet.
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in violation of official government orders requiring the wearing of face coverings while working under

This requirement is not met as evidenced by:

Based on interviews with a witness, staff members failed to properly wear face coverings while providing care and supervision to residents in care.
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Type A
06/27/2022
Section Cited
CCR
87465(a)(4)(5
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87465(a)(4)(5) Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
(4) The licensee shall assist residents with self-administered medications as needed.
(5) Facility staff, except those authorized by law, shall not administer injections, but staff designated by the licensee may assist persons with self-administration as needed. Assistance with self-administered medications shall be limited to the following:
(A) Medications usually prescribed for self-administration which have been authorized by the person's physician.
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Licensee shall conduct staff training on administering medication in accordance with medications that are prescribed by a physician. Licensee shall submit a staff training sign-in sheet. In addition, Licensee shall submit a summary on how future compliance will be met.
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This requirement is not met as evidenced by:

Based on a review of the Medication Assessment Record (MAR), the facility missed a medication pass for a resident on April 17, 2022 which is an immediate health, safety and personal rights risk to the residents in care.
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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: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 21-AS-20220429165154
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/01/2022
Section Cited
CCR
87506
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87506 Resident Records:
(a) The licensee shall ensure that a separate, COMPLETE, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
(14) Current centrally stored medications as specified in Section 87465, Incidental Medical and Dental Care Services.
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Licensee shall have resident records training and ensuring that ALL records are complete, current and properly maintained for each resident. Licensee shall submit a staff training sign-in sheet. In addition, Licensee shall submit a summary on how future compliance will be met.
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This requirement was not met as evidenced by:

Based on observation of the Medication Assessment Record (MAR), the staff member passing medication on April 17, 2022 did not document that a medication was missed for a resident which is a potential health, safety and personal rights risk to the residents in care.
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Type B
07/01/2022
Section Cited
HSC
1569.626(a)(1)
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Health and Safety Code1569.626 Training requirements for direct care staff:

(a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff:
(1) Twelve hours of dementia care training, six of which shall be completed before a staff member begins working independently with residents, and the remaining six hours of which shall be completed within the first four weeks of employment. All 12 hours shall be devoted to the care of persons with dementia. The facility may utilize various methods of instruction, including, but not limited to, preceptorship, mentoring, and other forms of observation and demonstration. The orientation time shall be exclusive of any administrative instruction.
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Licensee shall ensure that ALL staff who work with Dementia residents are trained to work with said residents. Licensee shall submit a staff training sign-in sheet. In addition, staff should be trained as soon as possible. Licensee shall submit a summary on how future compliance will be met.
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This requirement was not met as evidenced by:

Based off of staff record review, LPA identified 9 staff members that have not had the training that is identified in the Health and Safety Code to work with Dementia residents. Therefore, the staff members are out of compliance.
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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: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 21-AS-20220429165154
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/24/2022
Section Cited
CCR
87303
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87303 Maintenance and Operation: (i) Facilities shall have signal systems which shall meet the following criteria:
(1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall:
(A) Operate from each resident's living unit.
(B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff.
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Licensee shall conduct staff training on how call bells will be responded to and provide a 7 day log to Licensing along with training verification. In addition, Licensee shall submit a summary on how future compliance will be met.
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This requirement was not met as evidenced by:

Based off of record review, it was determined that a resident had to wait 1 hour and 40 minutes to be attended to which presents a health, safety and personal rights risk to the residents in care.
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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: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/29/2022 and conducted by Evaluator Farhaan Sarangi
COMPLAINT CONTROL NUMBER: 21-AS-20220429165154

FACILITY NAME:OAKMONT OF SAN RAFAELFACILITY NUMBER:
216804010
ADMINISTRATOR:LIBHART, JILLFACILITY TYPE:
740
ADDRESS:1 LAS GALINAS AVETELEPHONE:
(628) 336-1400
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:126CENSUS: 54DATE:
06/24/2022
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Resident Relations Director, Linda Nguyen.TIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Resident(s) personal rights were violated
Facility is in disrepair resulting in resident's room temperature not being maintained according to regulation.
Resident's medications were not managed properly.
Facility does not have operable keys for resident's rooms.
Not enough staffing to meet resident's needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Oakmont of San Rafael for the purpose of delivering complaint findings on a complaint that was initiated on April 29, 2022. LPA was greeted at the door by Concierge, Raymond, and granted access into the facility.

Complaint alleges that Resident(s) personal rights were violated. During the course of the investigation, LPA interviewed residents, staff members and witnesses. LPA learned throughout the investigation that the facility contracted with an outside agency and that a staff member was assigned to assist the facility with staffing. During the incident, the staff member went to check on residents and the residents did not want the staff member inside the room. Multiple attempts were made to contact the staff member of the outside agency, but were unsuccessful. LPA could not prove or disprove that the Residents Personal Rights were violated.

(Report continued on LIC 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 21-AS-20220429165154
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/24/2022
NARRATIVE
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Complaint alleges Facility is in disrepair resulting in resident's room temperature not being maintained according to regulation, Facility does not have operable keys for resident's rooms and facility does not have enough staffing to meet resident's needs. During the course of the investigation, LPA toured the facility on June 17, 2022, May 26, 2022 and May 4, 2022 and was granted access into the rooms. Facility staff members had operable keys to residents rooms and all parts of the facility. LPA did observe that the temperature of the facility was at a comfortable temperature with exits free from obstruction. LPA toured a sample of residents rooms that had a comfortable temperature. Residents appeared to be content and happy with the temperature in the facility. During the tours of the facilities on said dates, LPA observed the facility to be adequately staffed. In addition, during a document review, LPA found the LIC 500 to be appropriate during the investigation.

Complaint alleges Resident's medications were not managed properly. During the course of the investigation, LPA could not prove or disprove that the medications were not managed properly or that there was missing medication.

A finding that the complaint allegations of, Resident(s) personal rights were violated, Facility is in disrepair resulting in resident's room temperature not being maintained according to regulation, Resident's medications were not managed properly, Facility does not have operable keys for resident's rooms, Not enough staffing to meet resident's needs. are unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted and a copy of this was report was signed and given to the Resident Relations Director, Linda Nguyen.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 7