216804022-1-11-2024-21-AS-VBEI-CZK2KX-20240116162841

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216804022
Report Date: 01/11/2024
Date Signed: 01/11/2024 09:57:29 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
11/20/2023 and conducted by Evaluator David Leibert

COMPLAINT CONTROL NUMBER: 21-AS-20231120081148

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: 74	DATE:	01/11/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Liza Hix		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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9

Staff did not administer resident's medications as prescribed.
Staff did not ensure resident's medication is filled.

INVESTIGATION FINDINGS:

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Licensing Program Analyst Leibert arrives unannounced for the purpose of delivering findings on this complaint. Facility ran out of a medication for Resident (R1) resulting in missed administration of the medication on 10/29/2023 and 10/30/2023. Through statements and review of documents it has been determined that: Facility requested the medication refill 6 or 7 days before needed from the Medical Clinic; Facility Health Services Director states that the Medical Clinic delayed the refilling of the medication due to an internal communications issue and apologized for the delay but refused to put a statement in writing; Staff were unable to administer the medication on 10/29 and 10/30 due to the delay in obtaining the refill; Based upon statements and review of documents, it appears the facility made a reasonable attempt to obtain the medication before it was depleted; Although the allegations may be true or valid, there is not a preponderance of evidence to prove or disprove the allegations. Therefore, the allegations are UNSUBSTANTIATED.
Repot left.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
11/20/2023 and conducted by Evaluator David Leibert

COMPLAINT CONTROL NUMBER: 21-AS-20231120081148

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: 74	DATE:	01/11/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Liza Hix		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff do not communicate with resident’s authorized representative

INVESTIGATION FINDINGS:

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3
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5
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9
10
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12
13

Licensing Program Analyst Leibert arrives unannounced for the purpose of delivering findings on this complaint. Through an investigation that included statements from staff and witnesses; site visits to facility; review of pertinent documents and phone records, the following determinations are made: Facility ran out of a medication for Resident (R1) resulting in missed administration of the medication on 10/29/2023 and 10/30/2023; Facility staff state that R1’s Representative was notified of the medication issue by phone on 10/24,10/25, and 10/27; R1’s Representative states no notification of the medication problem was given until 11/01/2023; Representative’s phone records indicate no calls until 11/01 from the number given by facility as the number used to call R1’s Representative regarding the medication issue in October. Based upon the statements and documents, the preponderance of evidence standard has been met. Therefore, the allegation is SUBSTANTIATED. The following deficiencies were observed (see LIC 9099D) and 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. Exit interview conducted and appeal of rights provided.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 21-AS-20231120081148

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/11/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/15/2024 Section Cited CCR 87468.1(a)(8)	1 2 3 4 5 6 7	Personal Rights of Residents… Residents… shall have all of the following personal rights: To have their representatives regularly informed by the licensee of activities related to care or services … Based on statements and documents, requirement not met,	1 2 3 4 5 6 7	Administration will provide refresher training to appropriate staff on the requirements of 87468. Proof of training to be submitted to CCL by POC date in order to clear the deficiency.
	8 9 10 11 12 13 14	evidenced by: R1’s Representative not notified of medication issue timely. This posed an immediate violaltion of R1’s personal rights.	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 Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

LIC9099 (FAS) - (06/04)

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