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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804022
Report Date: 09/29/2022
Date Signed: 09/30/2022 10:08:15 AM

Document Has Been Signed on 09/30/2022 10:08 AM - It Cannot Be Edited

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
FACILITY NAME:OAKMONT OF NOVATOFACILITY NUMBER:
216804022
ADMINISTRATOR:PIELSTICK, RICFACILITY TYPE:
740
ADDRESS:1465 S. NOVATO BLVD.TELEPHONE:
(628) 215-1200
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY: 118CENSUS: 78DATE:
09/29/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Ric Pielstick - Executive DirectorTIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Fernandes-Goes arrived unannounced with the purpose of closing a complaint investigation. During subsequent complaint investigation LPA learned that there are related deficiencies observed during the visit. LPA met with Ric Pielstick - Executive Director. Following item was observed during investigation visit:

Department has learned that resident R1 had a fall on 7/22/2022 and R1 was sent to the ER, however; incident report was not provide/submitted to Department until LPA was visiting facility on 8/3/2022. In addition, Resident R2 had a medication refusal on 8/3/2022 that wasn’t reported to the Department. It was learned while reviewing records. (see records, LIC 809-D)

Appeal of Rights Given.

The following deficiencies were observed (see LIC 809D) 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.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2022
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 09/30/2022 10:08 AM - It Cannot Be Edited


Created By: Carla Fernandes-Goes On 09/29/2022 at 10:48 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: OAKMONT OF NOVATO
FACILITY NUMBER: 216804022

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/13/2022
Section Cited
CCR
87211

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87211 Reporting Requirements. This requirement is not met as evidenced by: Based on records reviewed, interview, facility didn't comply w/section cited above within 2 of2 residents incident reporting which poses a potential
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Facility to provide training to designated reporting staff to ensure that all incidents that need to be reported will be reported according with Title 22 Regulation. Facility to submit Department with proof of
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risk to their health, safety, personal rights for residents in care. Resident R1 and R2 had incidents that occurred on 7/22/22 & 8/3/22 which were not submitted to the department. (see docs, LIC 809)
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training, staff signatures , date , time and what was covered in addition to self certification that facility undestands this regulation by POC due date of 10/13/22.

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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 Moellers
LICENSING EVALUATOR NAME:Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2022


LIC809 (FAS) - (06/04)
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