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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804022
Report Date: 11/09/2023
Date Signed: 11/09/2023 03:09:23 PM


Document Has Been Signed on 11/09/2023 03:09 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:OAKMONT OF NOVATOFACILITY NUMBER:
216804022
ADMINISTRATOR:LIZA HIXFACILITY TYPE:
740
ADDRESS:1465 S. NOVATO BLVD.TELEPHONE:
(628) 215-1200
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY:118CENSUS: 74DATE:
11/09/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Executive Director, Liza HixTIME COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced at approximately 2PM and met with Executive Director (ED), Liza Hix to conduct a Case Management on Incident Reports received by CCL on 11/03/2023 and 11/08/2023. ED had to step away at end of visit due to a schedule conflict, Business Office Director, Tristan Amari went over report and signed.

Incident Report dated 11/03/2023 Resident 1 (R1) was found by staff on floor face down stating that Resident 2 (R2) hit them. R1 sustained an injury on their left elbow and was taken to the hospital for an evaluation. Both residents reside in Memory Care. Per conversation with ED, R2 walks swiftly through facility to get exercise, and it is believed that R2 bumped into R1 causing R1 to fall down. R2 does not have a history of violent behavior and there have not been any altercations between the residents since this incident.

Incident Report dated 11/08/2023 Resident 3 (R3) reported to staff that they were missing a watch valued at $200 and $50 in cash. Facility made a police report and helped R3 look for their missing items. The room was searched and missing items were not found. A phone call was made to R3s daughter who said that R3 loses things regularly and is known to find missing items in their pockets. LPA requested R3s Physicians Report that shows neither Mild Cognitive Impairment or a Dementia diagnosis. Per conversation with ED, R3 has plans to move out of facility. Should R3 decide to stay residing at facility, facility to arrange for R3 to receive an updated physicians report.

No deficiencies cited during visit.

Exit interview conducted, copy of report and confidential names (811) provided.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Helena RummondsTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2023
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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