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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804022
Report Date: 10/13/2023
Date Signed: 10/13/2023 03:19:18 PM


Document Has Been Signed on 10/13/2023 03:19 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 NOVATOFACILITY NUMBER:
216804022
ADMINISTRATOR:PIELSTICK, RICFACILITY TYPE:
740
ADDRESS:1465 S. NOVATO BLVD.TELEPHONE:
(628) 215-1200
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY:118CENSUS: 91DATE:
10/13/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
10:56 AM
MET WITH:Liza Hix (Executive Director)TIME COMPLETED:
03:34 PM
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Licensing Program Analysts (LPAs) Cuadra and Rummonds arrived at the facility to conduct an unannounced case management Legal/ Non-compliance inspection and cite deficiencies discovered during a complaint investigation met with Executive Director/acting Administrator Liza Hix. LPA was following 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. During facility tour, LPAs/Executive Director observed staff (S1) crushing medications for residents in care. LPAs were informed that there are physician's crush orders on file to crush medications for some residents (R1, R2, R3, R4, R5 & R6). However, there is no crush order from a physician in R1 & R4's file. Administrator requested LPAs time to locate crush orders and email them to for review. Administrator agreed that failure to provide physician's crush order to CCL will result in a citation. LPAs need to conduct further investigation and review prior to make a final determination.

Prohibited Conditions: Facility retained a resident with a prohibited condition. Facility provided resident's care notes to document daily resident's care notes and they are not maintained current month of October 2023. LPAs/Executive Director discussed the importance of documenting resident's care notes timely.



Medical Assessments: Facility failed to ensure that resident's medical assessments/physician's report is complete as required. LPA reviewed 6 resident (R1, R2, R3, R4, R5 & R6) medical records including their Physician’s reports (LIC602) had been updated within 12 months as indicated per regulation.

Timely Medical Attention: Facility failed to seek timely medical attention. LPA reviewed incident report logs received and residents have been assisted with timely medical attention as indicated per regulation. Continued on LIC809C...
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2023
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 3


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: 10/13/2023
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Continue from LIC809...

Facility Food Services: Facility kitchen area was toured by LPA/Executive Director and LPA found that perishable foods were stored in covered containers, and the refrigerator and freezer were at a temperature within 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 and R5) records indicated that residents have been assessed for change of condition within the last 12 months per regulation.

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/Executive Director reviewed LIC500 Personnel Summary and staff schedule for the month of October 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 2 out of 6 staff (S1 & S2) needs to receive 20 hours annual of additional training including medication training required per regulation.

Reporting Requirements: Facility failed to report refusal of medications, 911 calls, suspected abuse, etc. LPA reviewed incident report logs that revealed that facility has been reporting incidents to CCL within regulations. LPAs learned through records review and interviews with Administrator that incident report logs received and found incidents not submitted timely to CCL. Per investigation conducted of complaint #21-AS-20230901102047. Also, incident report, the incident occurred on 9/20/23, but it was received at CCL on 10/4/23 which is not within 7 days of occurrence as indicated per regulation.

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. Exit interview conducted with Executive Director and a copy of this report was given.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 10/13/2023 03:19 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: 10/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/27/2023
Section Cited
CCR
87211(a)(1)

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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require…(1) A written report shall be submitted to the licensing agency & person responsible for the resident within 7 days of the occurrence of any of the events…(B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirement has not been met as evidence by:
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Administrator to ensure all incidents that threaten the safety of residents are reported to CCL per regulation. Signed statement that the regulation was reviewed and sign in sheet for all staff trained to be submitted by POC due date.
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Based on LPA’s records review and interviews conducted Administrator did not ensure that CCL was notified of incidents involving R1 and R7, which poses a potential health & safety risk to residents in care.
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Deficiency Dismissed
Type B
10/27/2023
Section Cited
HSC1569.69(a)(1)

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§1569.69 Employees assisting residents with self-administration of medication; training requirements (a) Each RCFE licensed under this chapter shall ensure...the following training requirements: (1)...the employee shall complete 16 hours of initial training. This training shall consist of eight hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and eight hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment. This requirement is not met as evidenced by:
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Facility to submit written plan for all staff training including medication prior to assist with medications to ensure that staff has required training by POC due date.
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Based on record review & interview, the licensee did not comply with the section cited above in 2 out of 6 staff which poses/posed a potential health, safety or personal rights risk to persons in care.
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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 MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2023
LIC809 (FAS) - (06/04)
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