216804022-8-17-2023-21-AS-BMOS-CUYUQL-20230823154716

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216804022
Report Date: 08/17/2023
Date Signed: 08/17/2023 09:13:17 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
05/24/2023 and conducted by Evaluator Marisol Cuadra

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20230524142125

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:	ZIP CODE:	94947
CAPACITY:	118	CENSUS: 94	DATE:	08/17/2023
		UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Business Office Director Tristan Amari		TIME COMPLETED:	09:28 AM

ALLEGATION(S):

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-Failure to seek medical attention
-Neglect/Lack of Supervision

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Cuadra and Coppo arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with Business Office Director Tristan Amari.
Regarding the allegation of Facility staff failed to seek medical attention. On 5/24/23 resident (R1) concerns were raised by outside party regarding R1's right leg position and felt that R1 was in pain, where staff was advised to take R1 to Kaiser Hospital for evaluation. Per Reporting Party, Facility med-technician was shown R1's right leg position and informed that the resident appeared to be in pain-eyes closed with intermittent groaning. On 5/24/23 R1 was diagnosed with a right distal femur periprosthetic fracture. LPA contacted Reporting Party on 5/26/23 to gather any additional information regarding incident reports or any medical issues where the facility failed to seek medical attention for residents in a timely manner. Based on interviews conducted on 7/21/23 and 7/25/23 with staff and outside parties there was a consistency of verbal statements about R1 complaining of pain since R1’s admission date in February 2023.
Continued on LIC9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023

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-20230524142125

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
	VISIT DATE: 08/17/2023

NARRATIVE

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Continue from LIC9099...

Facility provided correspondence between the facility and responsible party including R1’s Physician report. Based on interviews conducted with outside parties indicate that there was an active communication with the facility regarding incidents involving R1. Based on medications review, the facility obtained a PRN order for Acetaminophen -500mg for pain three times per day such medication was included into R1’s care plan dated 2/11/23 due to R1 consistency complained of pain. Also, R1’s care notes for the month of May 2023 confirmed that on 5/18/23 R1 complained of right leg pain to an outside party. However, there was no indication that any incident including falls when medical attention was not provided by the facility. A finding that the complaint allegation Facility staff failed to seek medical attention is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Regarding the allegation of facility neglect/lack of supervision. According to Reporting Party, on 5/24/23 R1 was diagnosed with a fracture and there are concerns raised that the facility lack of supervision resulted in R1 sustaining a fracture. Based on records review, the facility provided LIC500 Personnel Summary and staff schedule for the month of June 2023. The facility has in Memory Care currently 4 care staff and 1 med tech, along with dining staff helping with meal service but not care. Based on records review, R1’s care plan indicated that residents needed assistance with full daily living activities. 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. On 7/21/23 and 7/25/23 LPA conducted confidential interviews with facility staff and outside parties did not indicate any lack of supervision that resulted in R1 sustaining a fracture. A finding that the complaint allegation facility neglect/lack of supervision is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

No deficiencies cited during today's visit.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023

LIC9099 (FAS) - (06/04)

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