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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804022
Report Date: 06/14/2022
Date Signed: 06/21/2022 09:30:20 AM


Document Has Been Signed on 06/21/2022 09:30 AM - 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:DOMIZIO, ANNEMARIEFACILITY TYPE:
740
ADDRESS:1465 S. NOVATO BLVD.TELEPHONE:
(628) 215-1200
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY:118CENSUS: 0DATE:
06/14/2022
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Kathleen Olson - Acting Executive DirectorTIME COMPLETED:
02:00 PM
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Licensing Program Manager Bethany Moellers, Licensing Program Analyst Carla Fernandes-Goes met with Kathleen Olson - Acting Executive Director, Sue McPherson - VP of Regulatory , Mark Maclaine - Vice President of Operations for Novato, Jimmy Duong - Regional Health Service Director Specialist. This meeting was conducted virtually due to COVID-19.

This meeting is being conducted to transfer a Compliance Plan Conference which started on July 2, 2021 due to facility new ownership. The following concerns were identified by the Licensing Agency in regard to the operation of this facility including but not limited to: Complaint investigations that have been substantiated and other concerns that have been observed such as:
Ø Medications: Facility had residents with unlocked medications in their possession who were not allowed to store and/or dispense medications according to physician's reports on file.

Ø Prohibited Conditions: Facility retained a resident with a prohibited condition


Ø Timely Medical Attention: Facility failed to seek timely medical attention.
Ø Medical Assessments: Facility failed to ensure that resident's medical assessments/physician's report is complete as required.
Ø Resident Records: Facility wasn't able to provide CCLD with pre-appraisals for resident's files that were reviewed.
Ø Staffing: Facility memory care didn't have adequate number of direct care staff to support each resident's physical, social, emotional, safety and health care needs.
Ø Facility Food Services:
Ø Reporting Requirements: Facility failed to report refusal of medications, 911 calls, suspected abuse, etc.

The Regional Office will re-review progress made on Non-Compliance Plan of 2 years from July 2, 2021.

Continued LIC 809-C
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2022
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: 06/14/2022
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The licensee was informed that additional civil penalties are under review by the Department per Health and Safety Code 1569.49 (f) due to substantiated complaint #21-AS-20210310171803 & # 21-AS-20210823100922 under formal facility #216803904 Oakmont of Novato.

There were no deficiencies cited at this time.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022
LIC809 (FAS) - (06/04)
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