216804022-3-21-2023-21-AS-CMAZ-CQ8VMX-20230324163415

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216804022
Report Date: 03/21/2023
Date Signed: 03/21/2023 10:37:53 AM

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
11/16/2022 and conducted by Evaluator David Leibert

COMPLAINT CONTROL NUMBER: 21-AS-20221116141751

FACILITY NAME:	OAKMONT OF NOVATO		FACILITY NUMBER:	216804022
ADMINISTRATOR:	PIELSTICK, RIC		FACILITY TYPE:	740
ADDRESS:	1465 S. NOVATO BLVD.		TELEPHONE:	(628) 215-1200
CITY:	NOVATO	STATE: CA	ZIP CODE:	94947
CAPACITY:	118	CENSUS: 78	DATE:	03/21/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Ric Pielstick		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Resident sustained an injury due to lack of care and supervision
Staff do not report incidents to resident's authorized person

INVESTIGATION FINDINGS:

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Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on the above captioned complaint allegations. LPA met with the Administrator and discussed the findings. This investigation included a thorough review of resident records and other documents; interviews with witnesses and staff; site visits to the facility. The following determinations are made: R1 has fallen and sustained injuries while in care; Facility incorporated fall prevention plan in R1's care plan; Record review indicateas that facility reported incidents per 87211 for R1 on a regular basis; Complainant could not provide sufficient details in order to investigatate a specific incident claimed to have gone unreported; Care notes suggest appropriate responses by care staff to R1's falls; Origins of some falls are unknown but sufficient evidence to link falls to lack of supervision was not found. Although the allegations may be true, based on statements; records and visits, there is not a preponderance of evidence to prove the allegations did or, did not, occur. Therefore, the allegations are UNSUBSTANTIATED.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023

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 3

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
11/16/2022 and conducted by Evaluator David Leibert

COMPLAINT CONTROL NUMBER: 21-AS-20221116141751

FACILITY NAME:	OAKMONT OF NOVATO		FACILITY NUMBER:	216804022
ADMINISTRATOR:	PIELSTICK, RIC		FACILITY TYPE:	740
ADDRESS:	1465 S. NOVATO BLVD.		TELEPHONE:	(628) 215-1200
CITY:	NOVATO	STATE: CA	ZIP CODE:	94947
CAPACITY:	118	CENSUS: 78	DATE:	03/21/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Ric Pielstick		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff not meeting resident’s needs

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on the above captioned complaint allegations. LPA met with the Administrator and discussed the findings. This investigation included a thorough review of resident records and other documents; interviews with witnesses and staff; site visits to the facility. The following determinations are made: R1 has dementia diagnosis and resides in memory care; R1 has history of falling while in care and requires a two person assist and can exhibit behaviors making care sometimes difficult for staff; Although care notes suggest regular bathing and routine care has been given to R1, two reliable witnesses state that R1 has been observed in a neglected state with unexplained injuries, needing bathing, changing and, in one instance, with feces under the finger nails. LPA observed R1 in a broken wheelchair at site visit of 01/12/2023. Based upon the statements provided and observations made, the preponderance of evidence standard has been met. Therefore, the allegation is SUBSTANTIATED.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023

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

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 21-AS-20221116141751

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: 03/21/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/27/2023 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	87464(f)(1) Basic Services. Basic services shall at a minimum include:(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). ***This requirement has not been met as evidenced by: Based on statements and observations, R1 has been	1 2 3 4 5 6 7	Administrator will submit a written plan which will outline training plans for Memory Care staff by the Director of the MC unit. Training to address actions to be taken going forward which are intended to insure regular and documented checks of residents for hygiene and general welfare. Plan to be signed, dated and submitted to
	8 9 10 11 12 13 14	observed in need of hygiene services, in a broken wheelchair and, on one occasion, with feces under the fingernails. This posed an immediate risk to the health and safety of R1.	8 9 10 11 12 13 14	CCL by POC date in order to clear the deficiency.
	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: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023

LIC9099 (FAS) - (06/04)

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