<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216804022
Report Date: 12/22/2022
Date Signed: 12/22/2022 04:20:26 PM

Substantiated


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
11/02/2022 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20221102125316
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: 91DATE:
12/22/2022
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Business Office Manager, Tristan AmirTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained multiply injuries due to a fall during a transfer
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst s(LPAs)Bertozzi and Nakagawa arrived unannounced to the facility to deliver findings regarding the complaint allegation above and met with Business Office Manager, Tristan Amir. Executive Director Ric Pielsitck was available by phone.

Resident sustained multiply injuries due to a fall during a transfer - Complaint alleges that resident was handled roughly by a caregiver because they attempted to transfer a resident by themselves resulting in multiple injuries. Per care plan, involved resident was a two person transfer and through interview, LPA confirmed that caregiver transferred resident by themselves. Review of chart notes and special incident report indicated that resident did sustain a skin tear and a head laceration and was treated at the hospital.

Continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 21-AS-20221102125316
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 NOVATO
FACILITY NUMBER: 216804022
VISIT DATE: 12/22/2022
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
26
27
28
29
30
31
32
Continued from LIC9099

Based on LPAs observations and record reviews, the preponderance of evidence standard has been met, therefore allegationsthat resident sustained multiply injuries due to a fall during a transfer are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 8), are being cited on the attached LIC 9099D.”)

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
11/02/2022 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20221102125316

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: 88DATE:
12/22/2022
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Business Office Manager, Tristan AmirTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Administrator did not report unusual incident as required
Facility is not addressing the mold issue
Uncleared adults providing care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst s(LPAs)Bertozzi and Nakagawa arrived unannounced to the facility to deliver findings regarding the complaint allegation above and met with Business Office Manager, Tristan Amir. Executive Director Ric Pielsitck was available by phone.

Administrator did not report unusual incident as required - It was alleged that the Administrator did not report the unusual incident to CCL. Based on record review an Incident Report was filed for incident involving resident, R1 though information received during investigation revealed that details of report may not be accurate.

Facility is not addressing the mold issue - Complaint alleges that beer keg has white mold all over it. LPA observed a white substance on a beer keg but was unable to identify it as mold. Keg is inaccessible to residents in care.

Continued on LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20221102125316
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 NOVATO
FACILITY NUMBER: 216804022
VISIT DATE: 12/22/2022
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
26
27
28
29
30
31
32
Continued from LIC9099A

Uncleared adults providing care - Based on review of Employee Roster provided by facility there is one staff who is not fingerprinted. Staff works in culinary and does not provide direct care to residents. Three other staff were identified as being cleared but not associated to the facility.

Allegations that Administrator did not report unusual incident as required, Facility is not addressing the mold issue and Uncleared adults are providing care are unsubstantiated meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the allegation occurred.

No deficiencies cited.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 21-AS-20221102125316
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 NOVATO
FACILITY NUMBER: 216804022
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/22/2022
Section Cited
CCR
87411(a)
1
2
3
4
5
6
7
87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
1
2
3
4
5
6
7
Facility to provide planned training date for designated carestaff to review the proper care and supervision following careplans according with Title 22 Regulation. Facility to submit Department with proof of
8
9
10
11
12
13
14
 This requirement is not met as evidenced by: Based on records reviewed, interview, staff transferred R1 by themself, rather than by 2-person assist as required in careplan, which poses an immediate risk to their health, safety, personal rights for residents in care.
8
9
10
11
12
13
14
training date by 12/23/22 and subsequent proof of training with staff signatures, date, time and what was covered in addition to self certification that facility undestands this regulation by POC due date of 01/09/23.
CCR
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 12/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5