<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804022
Report Date: 04/06/2023
Date Signed: 04/28/2023 10:51:06 AM


Document Has Been Signed on 04/28/2023 10:51 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 04/27/2023 09:46 AM

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

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
***Amended…On 4/6/2023 during case management inspection at this facility, LPA Cuadra issued in error the wrong citation #80075 (b) due to facility failed to administer medication per physician’s orders. LPA cited the facility under General Regulations instead of citing under Residential Care Facilities for the Elderly (RCFE) regulations. LPA Leibert will amend case management LIC809 and LIC809D reports and will be issuing the citation under RCFE Regulations. Also, civil penalties issued on 4/6/2023 was dismissed.

On 4/6/2023 Licensing Program Analyst (LPA) Cuadra conducted an unannounced case management Legal/ Non-compliance inspection to this facility and met with Executive Director/Administrator Ric Pielstick. 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. However, on 3/4/2023, CCL received a self-incident report notifying CCL that there was a medication error which occurred on 3/4/23 involving resident (R1) resulting in staff (S1) have received re-training on 3/5/2023 to prevent this type of incident from happening again. S1 recognized the error and contacted the physician and family. LPA was provided with S1 re-training records.

Prohibited Conditions: Facility retained a resident with a prohibited condition. Facility provided resident's care notes to document daily resident's care notes.



Timely Medical Attention: Facility failed to seek timely medical attention. LPA reviewed incident report logs received within 7 days as indicated per regulation.

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) medical records including their Physician’s reports (LIC602) which were found within compliance.

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.
Continued on LIC809C...
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2023
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: 04/06/2023
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
Continue from LIC809...
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/Lead staff reviewed LIC500 Personnel Summary and staff schedule for the month of March 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) has received hours annual of training required per 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.

During today’s visit, LPA followed up on a self-report SOC341 dated 4/4/2023 notifying CCL about a suspected physical abuse. The incident reported occurred on 3/31/2023 around 5pm between staff (S2) and resident (R2). Per report, the incident occurred on 3/31/23 at approximately 5:00pm when resident (R2) asked facility staff (S2) for some more lemonade, after serving it, R1 was observed upset took their cup of lemonade and water cup, poured it on the table, then took R3's cup of water and did the same thing. S2 turned around and said "don't do that R2", smacked their arm away, then R2 smacked S2 away from them. R2 continued to request more drink and kept throwing on the table for several minutes, then left the dining room. The incident was observed by S3 who file the report. Facility notified Community Care Licensing, Long Term Ombudsman and R1's responsible party about the incident and no concerns were raised by them. The facility also have conducted an internal investigation and provided LPA copies of written statement from S1, S2 and S3 describing their observations of the incident resulting in a not substantiated resolution. LPA also learned that the police has not been notified about the incident, LPA have advised the facility to cross report incident to the police department as soon as possible. LPA also conducted confidential interviews with residents and staff. However, this incident needs further investigation and review prior to make a final determination.

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.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 04/28/2023 10:52 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 04/27/2023 09:50 AM

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: 04/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
04/07/2023
Section Cited
CCR
87465(a)(5)

1
2
3
4
5
6
7

***Amended…87465 (a)(5) Incidental Medical and Dental Care Services. The licensee shall assist residents with self-administered medications when needed. This requirement is not met as evidenced by:

1
2
3
4
5
6
7
Administrator to ensure that all residents receive their medication as prescibed by their physician. Administrator has taken disciplinary action and provided retraining to Staff.

. ***Amended…civil penalties issued on 4/6/2023 was dismissed.

8
9
10
11
12
13
14


***Amended…Based on incident report of 3/4/23 and interviews conducted with facility staff. Facility failed to administer medication per physician’s orders which poses an immediate health and safety risk to clients in care.















8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Carla MartinezTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3