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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804022
Report Date: 06/01/2023
Date Signed: 06/01/2023 11:45:28 AM


Document Has Been Signed on 06/01/2023 11:45 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:PIELSTICK, RICFACILITY TYPE:
740
ADDRESS:1465 S. NOVATO BLVD.TELEPHONE:
(628) 215-1200
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY:118CENSUS: 79DATE:
06/01/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Liza HixTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on a complaint investigation. During the course of the investigation, it was learned that facility could not produce an inventory or waiver for the personal property of former resident, R1. Additionally, facility did not produce documentation that facility followed the Documentation of Loss procedures as outlined in page one of the facility’s Theft and Loss Policies and procedures when it was learned that glasses and hearing aides belonging to R1 were missing. 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: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2023
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 2


Document Has Been Signed on 06/01/2023 11:45 AM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/15/2023
Section Cited
CCR
87218(a)(1)

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87218(a)(1) Theft and Loss. The initial personal property inventory shall be completed by the licensee, and the resident, or the resident’s representative. *** Based upon statements and file research, this requirement has not been met as evidenced by:

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Administration will review the requirements of 87218(a)(1) and provide additional training to all staff providing intake to new residents. Proof of training to be submitted to CCL by POC date in order to clear the deficiency.
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 On or about April 06, 2023, facility staff were unable to produce the inventory for R1’s personal property. This posed a potential risk to the personal rights of R1.
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Type B
06/15/2023
Section Cited
CCR87208(a)

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87208(a) Plan of Operation. Each facility shall have... a current, written .. plan of operation. The plan.. shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect
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Administration will review 87208 and provide additional training to staff who deal with residents’ property concerns and will proceed with their stated policy regarding R1’s missing property. Proof of training and copy of Facility’s investigative report to be submitted
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the services to residents shall be submitted to the licensing agency for approval…***Based on statements and documents, this requirement not met as evidenced by: Facility did not follow Facility’s Loss policies in response to R1’s missing glasses and hearing aids. This posed a potential risk to personal rights of R1.
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Report to be submitted to CCL by POC date in order to clear the deficiency.
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 MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2