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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804022
Report Date: 03/01/2023
Date Signed: 03/01/2023 03:20:09 PM


Document Has Been Signed on 03/01/2023 03:20 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: 82DATE:
03/01/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Ric Pielstick, Administrator and
Tristan Amari, Business Office Director		TIME COMPLETED:
03:25 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) Nakagawa conducted a case management inspection and met with Ric Pielstick, Administrator. The purpose of the case management was to follow up on three self-reported

CCL received a self reported incident report on 2/12/23 for an incident that occurred on 2/10/23 when
Resident (R1) exhibited aggressive behaviors. Staff were able to intervene and re-direct. CCL received a second self reported incident report on 2/17/23 for an incident that occurred on 2/17/23
when R1 exhibited some agitation and aggressive behaviors when a staff member went in their room.
R1 pushed staff member and closed door. Staff was able to intervene and re-direct. Facility has increased supervision and put other methods in place to help with behaviors.

CCL received a third self-reported incident report on 2/23/23 for an incident on 2/19/23. It was reported that Resident (R2) did not receive regularly scheduled medications. LPA reviewed documentation and it was documented that R2 was not able to take medication at that time; the medication was not unintentionally missed.

\

No deficiencies cited at todays inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2023
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 1