216804010-2-24-2023-21-AS-CFES-CPCSBC-20230224124344

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216804010
Report Date: 02/24/2023
Date Signed: 02/24/2023 12:43:58 PM

Document Has Been Signed on 02/24/2023 12:43 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:	MELON RIVERA		FACILITY TYPE:	740
ADDRESS:	1 LAS GALINAS AVE		TELEPHONE:	(628) 336-1400
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	126	CENSUS:	DATE:	02/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Health Services Director, Cat Tomboc		TIME COMPLETED:	01:00 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	At approximately 9:10AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year Visit, and met with the front desk receptionist. Regional Sales Director, Vanessa Augusta, arrived during visit at approximately 9:35AM, and Health Services Director, Cat Tomboc, arrived at approximately 9:45AM. Administrator and Executive Director, Melon Rivera, was unavailable for today's visit. The inspection visit is focused on the Infection Control procedures and practices of this facility. Upon arrival at the facility, LPA checked in at the front desk. LPA conducted a walk-through of the facility and observed the following: COVID-19 signs were observed at the entry way and throughout the facility. Handwashing signs were observed in the bathrooms and at sinks. All staff and visitors resent were observed to be wearing a mask. The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility has a cleaning and disinfecting schedule that occurs daily. Facility has at least a 30-day supply of Personal Protective Equipment (PPE) and medication for Residents. Staff and Residents are screened daily for COVID-19 symptoms and it is logged into facility binders. LPA and Health Services Director discussed the following: Covid and Influenza A Protocols Staffing Resources and Staff Training Incident/Death Reports and Reporting Requirements Annual Inspection Expectations Facility has a plan in place if a staffing shortage were to occur. Facility has submitted their Mitigation/Infection Control Plan to Community Care Licensing (CCL). Continued on LIC809C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023

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: 02/24/2023

NARRATIVE

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Continued from LIC809

Fire extinguishers were last serviced April 2022. The last facility fire and evacuation drill was conducted in November 2022. Facility's fire alarm system was last inspected January 2023. Facility's elevators were last inspected February 2022.

LPA requested the following documents to update facility file:

Facility Documents

Administrative Organization (LIC 309)
Affidavit regarding Client/Resident Cash Resources (LIC 400)
Designation of Facility Responsibility (LIC 308)
Emergency Disaster Plan (LIC 610D)
Updated Personnel Report (LIC 500)
Current Administrator Certificate
Surety Bond (LIC 402)
Liability Insurance
Updated Register of Clients/Residents (LIC 9020)

Documents to be submitted to Community Care Licensing (CCL) by Friday, 3/24/2023.

LPA also followed up on a self reported incident that was submitted to CCL on 1/23/2023.

Incident Report 1: Report states that on 1/20/2023, Resident 1 (R1) was observed by staff to be grabbing Resident 2 (R2) by the arm. R2 was observed to be on the floor. Staff immediately intervened, separated the residents, and redirected them. Facility placed a one-on-one companion with R1. Facility made all appropriate notifications per regulation.

Continued on LIC809C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023

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: 02/24/2023

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Continued from LIC809C

Per conversation with Health Services Director, R1 and R2 are both Memory Care residents. When the incident occurred, R1 had recently moved to the facility and was still adjusting to their new environment. As of today, both residents have been doing fine. R1 was moved to a private room instead of a shared room. Facility has been working with R1's responsible party, one-on-one companion, and physician to regulate their behaviors and medication changes. R1 has been observed to be adjusting well to the community, and R2 has been observed to be at their baseline.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report and LIC811 (Confidential Names) discussed and provided to Health Services Director. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023

LIC809 (FAS) - (06/04)

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