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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804022
Report Date: 12/27/2023
Date Signed: 12/27/2023 02:54:58 PM


Document Has Been Signed on 12/27/2023 02:54 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
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: 84DATE:
12/27/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Executive Director- Liza Hix, Health Service Director- Kimari PinkneyTIME COMPLETED:
03:05 PM
NARRATIVE
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At approximately 1:20PM, Licensing Program Analyst (LPA) Helena Rummonds and Licensing Program Manager (LPM) Victoria Bertozzi arrived unannounced and met with Executive Director (ED), Liza Hix and Health Service Director, Kimari Pinkney to conduct a Case Management on Incident Report received by Community Care Licensing (CCL) on 11/27/2023.

Incident Report states that Resident was found wandering outside of facility grounds by local law enforcement at approximately 10PM. Based on conversation with ED and review of documents, Resident has a dementia diagnosis and is unable to exit facility unassisted. Resident has a history of exit seeking behavior. Resident returned to the community the same night. It is not clear why staff did not respond to the auditory device.

Facility has since conducted staff retraining, placed a wanderguard/ alert device on resident, has increased supervision and resident has a 1:1 companion.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Helena RummondsTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2023
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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Document Has Been Signed on 12/27/2023 02:54 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: OAKMONT OF NOVATO
FACILITY NUMBER: 216804022

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/28/2023
Section Cited
CCR
87705(j)

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87705 Care of Persons with Dementia
(j)The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement was not met as evidenced by:
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Facility conducted a staff retraining, increased supervision was implemented, and a 1:1 companion has been put in place for resident. Proof to be provided to LPA by POC due date of 12/28/2023.
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Based on interview and record review, the licensee did not comply with the section cited above by staff not responding to the auditory device on exit door in Memory Care Unit, allowing a resident to elope.
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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: Helena RummondsTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2023
LIC809 (FAS) - (06/04)
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