216804022-4-7-2022-21-AS-CFGS-CD9RSL-20220407131652

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216804022
Report Date: 04/06/2022
Date Signed: 04/07/2022 01:17:19 PM

Document Has Been Signed on 04/07/2022 01:17 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 NOVATO		FACILITY NUMBER:	216804022
ADMINISTRATOR:	DOMIZIO, ANNEMARIE		FACILITY TYPE:	740
ADDRESS:	1465 S. NOVATO BLVD.		TELEPHONE:	(628) 215-1200
CITY:	NOVATO	STATE: CA	ZIP CODE:	94947
CAPACITY:	118	CENSUS: 87	DATE:	04/06/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Kathleen Olson - Acting ED		TIME COMPLETED:	03:00 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	Licensing Program Analyst (LPA) Fernandes-Goes conducted a pre-licensing inspection and met with Acting Executive Director Kathleen Olson. Fire clearance has been approved for 110 non-ambulatory and 8 bedridden residents by the Marin County Fire Department. LPA will conduct a component III orientation with Kathleen Olson – Acting ED and Juan Ferrel – Traditions Director. There is a total of 87 residents with 32 residents in memory care. There are 6 residents currently on Hospice. LPA toured the facility on 4/6/2022 with Acting Executive Director Kathleen Olson; facility was found to be at a comfortable temperature with all exits free from obstruction. Facility is a two- story building in good repair and at a comfortable temperature. The main floor includes kitchen, dining area, activities area, bar and lounge, lobby, fitness area, beauty salon, bistro, reading room, living room, laundry room, office rooms, medication room, Traditions (memory care) and Assisted Living resident's bedrooms. Second floor includes media room, staff room, emergency food supply, assisted living resident's bedrooms. All residents' bedroom has their own bathroom. Traditions has 7 double bedrooms. Facility has several different activities available for residents as desired and has an activity calendar posted. There is outdoor space for activities. Menus for dining are posted on the table and at entrance. LPA observed that provisions are made for individuals with special dietary needs. Special diets are posted on a kitchen board with pictures and Traditions have a binder for special diets. Food stored in the kitchen refrigerator were properly stored as per regulations. Toxins are locked in chemical room on first floor. Facility also has community restrooms downstairs. There was a supply of cleaners, hygiene products and paper products available for residents. All bathrooms designated for residents at the facility were supplied with paper towels and hand soap dispensers. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. A sample tour of resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing. Mattress pads are available for residents. Continued LIC 809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022

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 NOVATO	FACILITY NUMBER: 216804022
	VISIT DATE: 04/06/2022

NARRATIVE

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Most postings noted to be current and in compliance with guidelines w/ only few missing. Locked cabinets for sharps and daily used toxins in Traditions were inaccessible to residents' in care. First aid kit was observed. PPE is stored in a storage room in memory care area. Exits were free from obstructions at the time of the visit. Fire Extinguisher was found to be last charged on 9/2021. Facility smoke detectors are hard wired and sound directly to the fire station. Smoke detectors and fire sprinklers are inspected annually. LPA observed single smoke and carbon monoxide detectors that were found to be operational. There are emergency lights in many of the fixtures in the common areas of the facility that come on should a power outage occurs. Hot water temperature measured between 102.5 degrees F and 118.5 degrees F falling out of Title 22 acceptable regulation of 105.0 to 120.0 degrees F required hot water temperature in 2 of 9 resident’s bathroom faucets. The facility has special care plan of operation and programming for residents with dementia. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations.

Facility understands that Disaster Drillsmust be conducted at least quarterly. Acting ED Kathleen stated that all staff is trained when hired on emergency preparedness and is aware were to shut off power, water, and so on. Facility has been advised to place a facility sketch with location of shut off power, water, and so on in a designated place that staff can see and located if needed.

Oakmont of Novato license # 216803904 has been licensed under OMG II INC and Oakmont of Novato LLC with following members Courtney Siegel, Crystal Dillard, CFO Kimberly Hynk and Susan McPherson. New Oakmont of Novato pre-license # 216804022 has as licensee Oakmont Management Group LLC OPCO and operating Agreement under Oakmont Management Group LLC with the following managers Courtney Siegel, Crystal Dillard, Matthew Stevenson, and Molly Flater.

Oakmont of Novato license # 216803904 at this time has 6 complaints pending investigation and 8 complaints closed – 7 substantiated and 1 unsubstantiated. From these 8 complaints, 2 complaints # 21-AS-20210310171803 & # 21-AS-20210823100922 have additional civil penalties that are under review by the Department per Health and Safety Code 1569.49 (f). Facility number # 216803904 will remain open until all complaints are closed and civil penalties are reviewed.

In addition, facility is under a 2 year non-compliance plan implemented on July 2, 2021 under facility # 216803904 will carry over to new license # 216804022 when approved and issued by the Department.

Continued LIC 809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022

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 NOVATO	FACILITY NUMBER: 216804022
	VISIT DATE: 04/06/2022

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Community Care Licensing has requested the following item be corrected prior to licensure:

- Provide a picture showing that the following postings have been placed in the facility: Non-Discrimination, Rights of Residents' Council, Theft & loss facility policy, COVID social distancing, symptoms, and coughing etiquette.
- Provide proof that hot water temperature is within Title 22 Regulations. - 5 day hot water temperature log.
- Facility provided Mitigation Plan that has been previously reviewed with changes that have been made by facility during this visit. Mitigation plan will be evaluated by Department prior to licensure.

There were no deficiencies cited at this time.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022

LIC809 (FAS) - (06/04)

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