216804010-4-14-2023-21-AS-CFES-CQVU47-20230414151439

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216804010
Report Date: 04/14/2023
Date Signed: 04/14/2023 03:14:49 PM

Document Has Been Signed on 04/14/2023 03:14 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: 81	DATE:	04/14/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Administrator/Executive Director, Melon Rivera		TIME COMPLETED:	01:15 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 11:20AM, Licensing Program Analyst (LPA) Felias, arrived unannounced to conduct a Case Management - Incident Visit and met with Administrator/Executive Director, Melon Rivera. The purpose of the visit was to follow up on self-reported incidents that were submitted to Community Care Licensing (CCL). LPA reviewed the following reports with Executive Director: Incident Report 1: CCL received an incident report on 03/24/2023. The report states that on 03/15/2023, Care staff observed swelling of Resident 1's (R1) knee while assisting with their care needs. Care staff also observed R1 to have pale skin. Care staff notified Emergency Personnel and R1 was transported to the hospital where they were diagnosed with a fracture. Facility made all appropriate notifications per regulation. LPA discussed R1 with Executive Director. Per conversation with Executive Director, Facility spoke with R1, their Responsible Party, and R1's Physician. All parties were unable to determine how the fracture occurred. As of today, 04/14/2023, R1 has returned to the community. Facility has updated R1's Physician's Report and Care Plan appropriately. Facility has continued to communicate with R1's Responsible Party regarding R1's care needs. Incident Report 2: CCL received an incident report on 04/03/2023. The report states that on 03/28/2023, Resident 2 (R2) was observed to be on the floor. Care staff notified Emergency Personnel and R2 was transported to the hospital where they were diagnosed with a fracture. 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: 04/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

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: 04/14/2023

NARRATIVE

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Continued from LIC809

LPA discussed R2 with Executive Director. Per conversation with Executive Director, R2 was observed to have changes in their mobility. Facility communicated with R2's Responsible Party regarding these observations and assisted in scheduling R2 to have Physical/Occupational Therapy done at the facility. As of today, 04/14/2023, R2 has moved out of the facility due to changes in care needs.

Incident Report 3: CCL received an incident report on 04/13/2023. The report states that on 04/09/2023, Care Staff observed Resident 3 (R3) on the floor of the facility's public restroom and to have a change in mental status. Care staff notified Emergency Personnel and R3 was transported to the hospital. Facility made all appropriate notifications per regulation.

LPA discussed R3 with Executive Director. Per conversation with Executive Director, R3 was being assisted to the bathroom by Care Staff. Care Staff left R3 to obtain supplies needed to assist R3 with their care needs. When the Care Staff came back, they heard a loud bang and observed R3 on the floor. As of today, 04/14/2023, R3 is back in the community and has been observed to be at their baseline. Facility has also conducted training for all staff.

LPA conducted a walk through with Executive Director/Administrator.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report and LIC 811 (Confidential Names) discussed and provided to Administrator. 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: 04/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

LIC809 (FAS) - (06/04)

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