216804022-7-21-2022-21-AS-CFGS-CGJUKU-20220721153944

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216804022
Report Date: 07/21/2022
Date Signed: 07/21/2022 03:54:33 PM

Document Has Been Signed on 07/21/2022 03:54 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: 83	DATE:	07/21/2022
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Ric Pielstick - Executive Director		TIME COMPLETED:	03:00 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	License Program Analyst (LPA) Fernandes-Goes arrived unannounced to conduct a Non-Compliance Post Licensing Infection Control inspection to this facility. LPA was welcomed by front desk staff Emily who contacted Memory Care Director (MCD) Juan Ferrel and ED Ric Pielstick. There are 83 residents (52 AL and 31 MC) with 3 under hospice at facility. Facility has activities planned for residents during the day. LPA arrived at the facility and had her temperature checked and logged. During facility tour on 07/21/2022 with MCD Juan; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Exits in memory care were equipped with delay egress that were working properly during the visit. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 09/2021 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. Hot water temperature measured between 107.2 degrees F and 119.3 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 6 out of 6 residents' bathroom faucet while touring facility. The facility serves residents with dementia and has a plan of operation for special care and programming. There is a daily activity schedule for residents. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of visit. LPA learned that there are provisions made for residents with special dietary needs. 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. Toxins are stored in a locked cabinet inside the laundry area. Dangerous items were stored inaccessible to clients. There was a supply of cleaners, hygiene products and paper products available for clients. All resident’s bedrooms have lighting & appropriate furnishings. Continued LIC 809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022

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 4

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: 07/21/2022

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
26
27
28
29
30
31
32

A review of six resident records as well as two resident’s medications was conducted. LPA reviewed resident’s files and learned that 6 of 6 residents have an updated re-appraisals/needs & care plans and physician’s assessments (LIC 602A).

Infection Control:
Facility has submitted a mitigation program plan that has been approved. Some posters have been placed at entrance and common bathrooms. Facility has hand sanitizer available for visitors. Staff before coming into work have temperature checked. Facility has PPE supply stored in memory care storage area. There has been new staff hired and new resident’s admission since COVID. Residents’ medications are stored and locked in medication room inside medication cart. Facility has a 30-day supply of medication for clients. Residents are not wearing masks inside the facility, however; staff stated that they are able to wear masks when going on outings. All staff had masks on during this visit. In addition, facility is allowing visitors inside after temperature check. Residents have available virtual and telephone calls when contacting with family members and others. Staff have had all PPE training required on file and have acquired N-95 fit testing for staff.

There were no deficiencies cited at this time.

Department is requesting facility to submit the following update documents by 07/28/2022 to the Department:

LIC 308 Designated
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 610E-S Supplemental Emergency Disaster Plan for RCFE
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Certificate of Liability Insurance
Copy of last annual Smoke detectors and fire sprinklers inspection

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022

LIC809 (FAS) - (06/04)

Page: 2 of 4