216804022-3-28-2024-21-AS-HRUS-D3STQT-20240328145627

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216804022
Report Date: 03/28/2024
Date Signed: 03/28/2024 02:56:42 PM

Document Has Been Signed on 03/28/2024 02:56 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 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: 75	DATE:	03/28/2024
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Executive Director, Ric Pielstick		TIME COMPLETED:	03:10 PM

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Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced at approximately 10:45AM to conduct a non-compliance inspection. LPA followed up on the following areas which were initially addressed during a non-compliance meeting dated 07/21/2021. LPA met with Executive Director, Ric Pielstick.

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.
LPA observed medications to be double locked in medication room. LPA and Health Services Director (HSD) toured the Memory Care unit and conducted an inspection of 3 residents apartments. 3 of 3 apartments did not contain any unlocked medications.

Prohibited Conditions: Facility retained a resident with a prohibited condition.
LPA reviewed a sample of 3 Memory Care and 3 Assisted Living files. 0 of 6 resident files reviewed contained evidence of a resident being retained with a prohibited health condition.

Timely Medical Attention: Facility failed to seek timely medical attention.
LPA reviewed incident reports and confirmed that facility has been seeking timely medical attention.

Medical Assessments: Facility failed to ensure that resident's medical assessments/physician's report is complete as required.
LPA reviewed a sample of 3 Memory Care and 3 Assisted Living files. 6 of 6 files had medical assessments completed as required per regulation.

Continued on LIC809C

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Helena Rummonds	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024

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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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
	VISIT DATE: 03/28/2024

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Continued from LIC809

Resident Records: Facility wasn't able to provide CCLD with pre-appraisals for resident's files that were reviewed.
LPA reviewed a sample of 3 Memory Care and 3 Assisted Living files. 1 of 6 files reviewed did not have a pre-admission appraisal.

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 reviewed LIC500 Personnel Report as well as facilities employee roster which indicates which department each individual works in. LPA confirmed with Memory Care Director that there are 4-5 Caregivers on shift during AM and PM shifts, as well as 2 Medication Technicians, and at least 4 NOC shift throughout the facility.

Facility Food Services: Facility kitchen area was toured by LPA and Business Office Director. LPA found that perishable foods were stored in covered containers, and the refrigerator and freezer were at a temperature within regulation.

Reporting Requirements: Facility failed to report refusal of medications, 911 calls, suspected abuse, etc.
LPA reviewed regulation 87211 with HSD and discussed the importance of reporting accurately and within seven days as required per regulation. LPA reviewed incident reports and confirmed that there were four incident reports received since October of 2023 that were received by CCL past the required seven day limit.

No deficiencies cited during inspection.

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Helena Rummonds	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024

LIC809 (FAS) - (06/04)

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