216804022-6-29-2023-21-AS-MCUA-CT9U7L-20230629152006

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216804022
Report Date: 06/29/2023
Date Signed: 06/29/2023 03:20:19 PM

Document Has Been Signed on 06/29/2023 03:20 PM - 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 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:	06/29/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:29 AM
MET WITH:	Ric Pielstick (Administrator)		TIME COMPLETED:	03:35 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Cuadra conducted an unannounced case management Legal/ Non-compliance and Annual Required inspection to this facility and met with Executive Director/Administrator Ric Pielstick. There are residents (48 AL and 31 MC) with 4 under hospice at facility. The facility serves residents with dementia and has a plan of operation for special care and programming. LPA/Administrator toured the facility around and made the following observations: Tour included resident apartments, kitchen, food storage, dining room and various common areas used by residents. Facility was a comfortable temperature and passageways were free from obstructions. Exits in memory care were equipped with delay egress that were working properly during the visit. Fire Extinguisher was found to be last charged on 09/2022 at the time of the visit. Sample test of Smoke Detectors & Carbon monoxide detector were found to be operational during this visit. Smoke detectors and fire sprinklers are annually inspected June 2023. Most recent fire/disaster drill was conducted June 2023. Resident rooms were furnished per regulation. Water temperature in various sinks accessible to residents in care measured at 115.2, 109.8 (x2), 108.3, 110.8, 114.3, 113.1, 115.3 and 114 degrees F which are within the range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Cleaning supplies are locked in supply closets as well as mobile housekeeping carts. Dangerous items were observed locked and not accessible to residents in care. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality, stored per regulation and there are residents with special diets needs that are been provided by the facility. Facility kitchen has a binder and posted on the wall with all resident’s names, pictures, and their needs. Food is available for residents any time of the day. Medications were centrally stored, locked in medication room, they were reviewed. There is a daily activity schedule for residents. At approximate 9:30am LPA/Administrator observed bathroom toilet in room# 124 needed assistance, there were feces on the toilet and bathroom floor. Administrator called staff immediately to clean the bathroom. Continued on LIC809C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023

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: 06/29/2023

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LPA initiated file review of ten staff files and ten resident files. All staff reviewed have required 1st Aid, CPR certificates and annual training hours. Administrator Certificate for Ric Pielstick 6055213740 expires 8/26/2024. LPA also followed up on items that were concerning and ensure compliance with Non-Compliance Conference dated 7/2/21:

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. At the time of inspection Medications were stored and locked at all times.

Prohibited Conditions: Facility retained a resident with a prohibited condition. Facility provided resident's (R1, R2, R3, R4, R5, R6, R7, R8, R9 & R10) care notes to document daily resident's care notes. However, 8 out 10 resident's care notes have not been updated since May 2023.

Timely Medical Attention: Facility failed to seek timely medical attention. LPA/Administrator pulled the call alert button that pages staff to come and assist residents with their needs. Staff responded to call button timely in rooms# 128, 124, 120 and 107 located in Memory Care area.

Medical Assessments: Facility failed to ensure that resident's medical assessments/physician's report is complete as required. LPA reviewed 10 resident (R1, R2, R3, R4, R5, R6, R7, R8, R9 & R10) medical records including their Physician’s reports (LIC602) which 1 out of 10 files were not within compliance. R7's medical assessment needs to be updated.

Facility Food Services: Facility kitchen area was toured by LPA/Memory Care Director and LPA found that perishable foods were stored in covered containers, and the refrigerator and freezer were at a temperature within regulation.

Reporting Requirements: Facility failed to report refusal of medications, 911 calls, suspected abuse, etc. LPA reviewed incident report logs that confirmed that facility has been reporting incidents to CCL within regulations. Continues on LIC809C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023

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: 06/29/2023

NARRATIVE

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Continued from LIC809C...
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. LPA/Lead staff reviewed LIC500 Personnel Summary and staff schedule for the month of June 2023. Facility has in Memory Care currently 4 care staff and 1 med tech, along with dining staff helping with meal service but not care. LPA reviewed staff training records and most of staff (S1, S2, S3, S4, S5, S6, S7, S8, S9 & S10) has received hours annual of training required per regulation.

Resident Records: Facility wasn't able to provide CCLD with pre-appraisals for resident's files that were reviewed. LPA reviewed and learned that residents (R1, R2, R3, R4, R5, R6, R7, R8, R9 & R10) records indicated that residents have been assessed for change of condition within the last 12 months per regulation.

During today’s visit, LPA followed up on three incident reports occurred between 6/12/23 and 6/20/23 notifying CCL about a suspected financial abuse. First incident reported dated 6/12/23 when it was reported by resident (R1) to Administrator indicating that there were $260 missing from their apartment. According to R1, $60 were missing from a drawer in their kitchen and $200 missing from another location in the apartment. The second incident noticed by R1 was on 6/20/23, this time a missing pair of gold cabochon earrings were missing, they were last seen on 6/16/23. Staff went through the apartment and helped R1 to look for them and it was confirmed that items were missing. Responsible parties were notified including the police case# 23-2183. The last incident occurred between 6/15/23 to 6/18/23 when it was noticed on 6/18/23 by resident (R2) that there were three items missing as followed from their apartment: two platinum bands with diamonds, and one 14k gold diamond ring. The items were kept on a glass tray on the right night stand, staff once again helped searching for items unsuccessfully, the Items were last seen on 6/15/23. The facility notified responsible parties including Novato Police Department tracking #T23000276.

The facility is currently conducting an internal investigation, Administrator agreed to provide a copy of their findings that are assumed to be completed by 6/30/23. However, this incident needs further investigation and review prior to make a final determination.

Continues on LIC809C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023

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: 06/29/2023

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At approximate 1:00pm LPA/Administrator observed while conducting file review that staff (S9) was not associated to the facility. LPA informed Administrator that S9 is not associated to facility and should never be working and providing care to residents prior to a criminal record clearance or exemption. *** Civil penalties are being assessed in the amount of $100 per day for allowing a person to work, reside or volunteer in the facility without a fingerprint clearance exemption.

Administrator agreed to submit updates of the following documents by 7/14/2023: LIC308 Designation of Facility Responsibility, Copy of Liability Insurance, LIC 610 Emergency Disaster Plan (If changes) and Infection Control Plan (If changes)

Deficiencies 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. Appeal rights given.

The Northern California/Adult Program Regional Office has scheduled an Informal meeting with Licensee and pertinent parties to follow up on areas of concerns.

Exit interview conducted with Administrator and a copy of the report was given.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/29/2023 03:20 PM - 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: 06/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Deficiency Dismissed

Type A

Section Cited

CCR

87303(a)(1)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA/Administrator observations, the licensee did not comply with the section cited above in bathroom located at room#124 needed assistance, toilet and bathroom floor have feces on it, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/30/2023
	Plan of Correction
1 2 3 4	Administrator will submit a written statement in how the facility staff will ensure compliance with regulation by POC due date to clear the citation.

Request Denied

Type A

Section Cited

CCR

87355(e)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA/Administrator observation, records review and interview with Administrator did not ensure to obtain a criminal record clearance for staff (S9) prior to work, reside or provide care to residents in care which poses an immediate health, safety and personal rights risk to residents in care. ***Civil Penalty is being assesed for the amount of $100 per day.
	POC Due Date: 06/30/2023
	Plan of Correction
1 2 3 4	Administrator associated staff (S9) as required by law. Administrator will submit a self-certification that S9 was transferred and associated to the facility to CCL by POC due date.

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: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/29/2023 03:20 PM - 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: 06/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(a)

Medical Assessment

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA/Administrator observation, interview and record review, the facility staff did not comply with the section cited above in 1 out of 10 resident's diagnosed with Dementia medical assessments was performed within the last 12 months as indicated per regulation, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/14/2023
	Plan of Correction
1 2 3 4	Administrator agreed to provide evidence through self-certification of current medical assessments for 1 resident to CCL by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023

LIC809 (FAS) - (06/04)

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