216804010-4-25-2023-21-AS-KMOA-CRAMLQ-20230427094242

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216804010
Report Date: 04/25/2023
Date Signed: 04/25/2023 03:17:30 PM

Unsubstantiated

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
04/11/2023 and conducted by Evaluator Caitlynn Felias

COMPLAINT CONTROL NUMBER: 21-AS-20230411121803

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: 72	DATE:	04/25/2023
		UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Administrator/Executive Director, Melon Rivera		TIME COMPLETED:	03:25 PM

ALLEGATION(S):

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Personal Rights

INVESTIGATION FINDINGS:

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At approximately 2:45PM, Licensing Program Analyst (LPA) Felias arrived unannounced to deliver findings for a Complaint Investigation regarding the above allegation and met with Executive Director/Administrator, Melon Riveria.

During the course of the Investigation, Licensing Program Analyst (LPA) Felias reviewed and requested documents and conducted interviews.

There is an allegation of Personal Rights. The Reporting Party (RP) reported that the Facility allowed an individual to visit Resident 1 (R1) who was not allowed to do so. Review of R1’s Records indicated that there is no legal or medical documentation stating who is permitted to visit with R1. Interviews conducted indicated that the facility has continued to follow their visitation policy appropriately and has a plan in place to ensure that R1’s personal rights are not being violated.
Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20230411121803

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: 04/25/2023

NARRATIVE

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Continued from LIC9099

A finding that the complaint allegation of “Personal Rights” is UNSUBSTANTIATED.

A finding that the complaint is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

No deficiencies cited during visit.

Exit interview conducted. Copy of report and LIC811 (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: 04/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023

LIC9099 (FAS) - (06/04)

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