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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804022
Report Date: 01/19/2023
Date Signed: 01/19/2023 05:30:06 PM


Document Has Been Signed on 01/19/2023 05:30 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 NOVATOFACILITY NUMBER:
216804022
ADMINISTRATOR:PIELSTICK, RICFACILITY TYPE:
740
ADDRESS:1465 S. NOVATO BLVD.TELEPHONE:
(628) 215-1200
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY:118CENSUS: 79DATE:
01/19/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Ric Piehlstick, AdministratorTIME COMPLETED:
10:05 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced on 1/19/2023 to conduct a Case Management Legal/Non-Compliance visit. LPA was greeted by staff and screened before entry into the facility and logged in to the Visitor's Log. LPA met with Ric Pielstick, Administrator, and then went to inspect Traditions (Memory Care). Traditions has a new director, who is already setting up several training sessions. The memory care unit was clean and orderly and a comfortable temperature of 71 F. Residents' rooms varied by several degrees, depending on personal preference. Toxins were secured and not accessible to residents. Each room has a locking cupboard for storing toxins and soaps, making them inaccessible to residents. There were four (4) care staff in Traditions at the time of inspection, as well as one Activities Director, one Med. Tech. and the Traditions Director. Staffing in Traditions was adequate at the time of inspection.

LPA toured the kitchen, dining room and lounge area and found the area clean and orderly. The Lounge has beer and wine, which is locked and inaccessible to residents. The Outdoor Courtyards were clean and inviting, despite all the recent rains, residents had a safe, dry space to access outside.

LPA reviewed eight (8) Resident files, which were complete and up to date. All staff present at the facility were fingerprinted and associated.

During this inspection, LPA followed up on an incident report that was submitted on 11/26/2022 which involved a medication error which occurred on 11/25/22 at 10 AM. The staff member (S1) recognized the error and contacted the physician and family.

(Continued on 809-C)
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


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: 01/19/2023
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(Continued from 809)

During this inspection, LPA followed up on an incident report that was submitted on 11/26/2022 which involved a medication error which occurred on 11/25/22 at 10 AM. The staff member (S1) recognized the error and contacted the physician and family.


Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

This report was reviewed with Administrator and Appeal rights were given.

SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 01/19/2023 05:30 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/19/2023
Section Cited

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80075(b) Health Related Services. Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement is not met as evidenced by:
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Administrator/Licensee to ensure that all clients receive their medication as prescibed by their physician. Administrator has taken disciplinary action and provided retraining to Staff. Additionally, continuing a training on 1/26/23. A list of attendees and training materials will be submitted to LPA by 1/28/23.
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Based on incident report of11/26/22 and interview withmedical staff at facility, S1 failed to ensure that resident received the right dosage of medication as prescribed by physician which poses an immediate health and safety risk to clients in care.
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A

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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: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3