216804022-12-27-2023-21-AS-BMOS-CZ5TV2-20240103140309

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216804022
Report Date: 12/27/2023
Date Signed: 12/27/2023 02:52:28 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/09/2023 and conducted by Evaluator Helena Rummonds

COMPLAINT CONTROL NUMBER: 21-AS-20231109142722

FACILITY NAME:	OAKMONT OF NOVATO		FACILITY NUMBER:	216804022
ADMINISTRATOR:	LIZA HIX		FACILITY TYPE:	740
ADDRESS:	1465 S. NOVATO BLVD.		TELEPHONE:	(628) 215-1200
CITY:	NOVATO	STATE: CA	ZIP CODE:	94947
CAPACITY:	118	CENSUS: 84	DATE:	12/27/2023
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Executive Director- Liza Hix, Health Service Director- Kimari Pinkney		TIME COMPLETED:	01:20 PM

ALLEGATION(S):

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Failed to seek timely medical resulting in resident death
Staff does not meet residents care needs
Staff stole residents medication

INVESTIGATION FINDINGS:

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At approximately 10:30AM, Licensing Program Analyst (LPA) Helena Rummonds and Licensing Program Manager (LPM) Victoria Bertozzi arrived unannounced to continue a Complaint Investigation regarding the above allegations and met with Executive Director, Liza Hix and Health Service Director, Kimari
Pinkney.

Complaint alleges a resident was vomiting and not feeling well but there was a delay in sending them to the hospital resulting in them passing away at the hospital. Per interviews conducted, resident did not show signs of illness preceding the vomiting episode. Interview revealed that following vomiting episode, the resident continued to be monitored until their symptoms escalated, requiring them to be sent to the hospital.

Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Helena Rummonds	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20231109142722

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 12/27/2023

NARRATIVE

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Continued from LIC9099

Complaint alleges that medications have gone missing due to staff members stealing residents medications. Facility staff explained their destruction policy and provided LPAs with destruction record. LPAs observed receptacle that destroyed medications are in. Based on interviews conducted and review of destruction record, LPAs were unable to find evidence to support the allegation.

Complaint alleges that a resident had a pressure injury that was not receiving medical attention and that staff are expected to assist with self administration of medication without training. Based on document review, resident had a blister on their foot that is not identified as a pressure injury. Document review showed that resident's doctor and responsible party were notified of the blister. Review of training does not support allegation that staff are not trained.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated.

No deficiencies cited during this inspection.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Helena Rummonds	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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