216804022-4-6-2023-21-AS-KMOA-CRAV2C-20230427160256

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216804022
Report Date: 03/01/2023
Date Signed: 04/06/2023 11:22:18 AM

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
02/23/2023 and conducted by Evaluator Jill Nakagawa

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20230223143406

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: 82	DATE:	03/01/2023
		UNANNOUNCED	TIME BEGAN:	10:25 AM
MET WITH:	Ric Pielstick, Administrator and Tristan Amari, Business Office Manager		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Staff are not preventing resident's television from interfering with another resident's sleep

INVESTIGATION FINDINGS:

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***AMENDED - Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an investigation regarding the above allegation and met with Administrator Ric Pielstick.
During the investigation, LPA reviewed/obtained records, made observations and conducted interviews.
It is alleged that Staff are not preventing resident's television from interfering with another resident's sleep. Resident (R1) lives in an adjoining apartment to resident (R2) and resident (R3) who share an apartment together. R1 claims that the television volume increased when R3 recently started residing with R2. LPA reviewed Appendix C (Statement of residents personal rights) of the facility house rules which state in part “ We request that all residents monitor the volume of their televisions…” Interviews with staff (S1 & S2) found that they had been asked to check the television sound level by complaint of R1. R2 stated to staff they would turn down their TV, but failed to do so. S3 stated that they observed the sound level of the television to be elevated when R1 complained to S3. Based on LPA’s review of documentation, observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. The following deficiency was cited on the attached LIC 9099-D 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.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20230223143406

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: 03/01/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type B 03/01/2023 Section Cited CCR 87468.1(a)(3)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(3)To be free from... interfering with daily living functions such as eating, sleeping, or elimination. ***This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator to submit a plan of action to address to CCL by POC due date of 03/07/2023.
	8 9 10 11 12 13 14	Based on record review, interviews conducted and observations, licensee did not ensure the regulation above due to R2 and R3's occasional loud television volume which violated R1's ability to sleep. This is a potential personal rights risk to clients in care.	8 9 10 11 12 13 14
	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 Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023

LIC9099 (FAS) - (06/04)

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