216804022-6-1-2023-21-AS-HDBI-CSQNPS-20230612103849

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216804022
Report Date: 06/01/2023
Date Signed: 06/01/2023 11:41:23 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
03/17/2023 and conducted by Evaluator David Leibert

COMPLAINT CONTROL NUMBER: 21-AS-20230317123457

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: 79	DATE:	06/01/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Liza Hix		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff did not safeguard resident's personal belongings
Staff did not meet resident's incontinence needs
Staff did not properly supervise resident
Staff did not assist resident with showering

INVESTIGATION FINDINGS:

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Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. LPA met with Marketing Director and discussed the allegations. During the course of this investigation, this Department has interviewed witnesses and staff, reviewed and obtained documents, and made site visits to the facility. The following determinations are made: Personal belongings of R1, including glasses and hearing aides, were lost, stolen or misplaced while R1 was in care; Although the Licensee did not follow the required investigative and documentation requirements, it remains unknown how the belongings were removed from R1's possession; Statements made by current and former staff, as well as care note entries for R1, illustrate that when R1's spouse was not present at the facility, R1 often refused bathing and changing attempts by staff and could become agitated and aggressive; Facility care notes are kept for 30 days and not all notes were available for review. Although the allegations may be true, based on the statements and documents reviewed, there is not a preponderance of evidence to prove the allegations are or, are not, valid. Therefore, the allegations are UNSUBSTANTIATED.
No citations issued. Report left.

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: 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.

LIC9099 (FAS) - (06/04)

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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
03/17/2023 and conducted by Evaluator David Leibert

COMPLAINT CONTROL NUMBER: 21-AS-20230317123457

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: 79	DATE:	06/01/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Liza Hix		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

1
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9

Staff did not refund responsible party after resident moved out of the facility

INVESTIGATION FINDINGS:

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Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings
on this complaint. LPA met with Liza Hix and discussed the allegations. During the course of this
investigation, this Department has interviewed witnesses and staff, reviewed and obtained
documents, and made site visits to the facility. The following determinations are made:
According to the Facility’s Business Manager, R1 gave notice on January 25, 2023 and the rent
end date, allowing for 30 day notice, was February 25, 2023; According to the Facility’s
Administrator, in an e-mail dated 04/20/2023, “ The (refund) check is being hand delivered to
her ( the Responsible Person) today.” Health and Safety Code Section 1569.652 provides, in
part, ….refund of fees paid in advance…after resident’s personal property has been
removed…shall be issued…within 15 days. Based upon the documents reviewed and statements
taken, the preponderance of evidence standard has been met. Therefore, the allegation is
SUBSTANTIATED. The following deficiencies were observed (see LIC 9099D) 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.
Cite:

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: 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.

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 21-AS-20230317123457

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: 06/01/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/08/2023 Section Cited HSC 1569.652(c)	1 2 3 4 5 6 7	1569.652 (c). A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual, individuals, or entity contractually responsible for the fees or, if the deceased, resident paid the fees, to the resident’s estate, within 15 days after the personal property is removed.	1 2 3 4 5 6 7	Administration to review H&S 1569.652 and produce a signed, dated declaration which addresses how compliance with refund requirements will be met going forward. Declaration to be submitted to CCL by POC date in order to clear the deficiency
	8 9 10 11 12 13 14	*Based on statements/documents this requirement not met as evidenced by:R1’s refund was due 15 days after 2/25/2023 but was not made until on or about 4/20/2 This posed an immediate violation of R1’s personal rights.	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: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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