216804022-6-20-2024-21-AS-JMAS-D6F22X-20240620170125

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216804022
Report Date: 06/20/2024
Date Signed: 06/20/2024 05:01:35 PM

Document Has Been Signed on 06/20/2024 05:01 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:	RIC PIELSTICK		FACILITY TYPE:	740
ADDRESS:	1465 S. NOVATO BLVD.		TELEPHONE:	(628) 215-1200
CITY:	NOVATO	STATE: CA	ZIP CODE:	94947
CAPACITY:	118	CENSUS: 78	DATE:	06/20/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Ric Pielstick, Administrator		TIME COMPLETED:	05:16 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Helena Rummonds and Jacky Macias arrived unannounced at approximately 9:30AM to conduct an Annual Required inspection and was greeted by staff. LPAs and staff discussed the purpose of the visit to Administrator Ric Pielstick. At approximately 9:45am, LPAs and staff initiated a tour of the facility which included resident apartments, kitchen, food storage, dining room and various common areas used by residents. Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in various restroom sinks accessible to residents in care were all within the range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Cleaning supplies are locked in supply closet. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality, stored per regulation. There are residents with special diets needs that are being provided by the facility. Facility kitchen has a binder and posted on the wall with all resident’s names, pictures, and their needs. Food is available for residents any time of the day. There is also a daily activity schedule for residents. Upon touring the Memory care unit, LPAs observed a residents bed sheets to be wet and having an incontinence odor throughout the Memory Care unit. Medications are centrally stored in a secured room and were reviewed. Emergency food and water supplies are stored in a secured room. Personal Protective Equipment is stored in PPE closet. Fire extinguishers were last serviced September 22, 2023. Facility has combination smoke and carbon monoxide detectors as well as a sprinkler system that is serviced by an outside vendor that was last inspected on 06/12/2024. Most recent fire/disaster drill was conducted 06/20/2024. Continued on LIC809C...

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jacqueline Macias	TELEPHONE: (707) 588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024

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: 06/20/2024

NARRATIVE

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Continued from LIC809

Ten staff files and ten resident files were reviewed. Staff have required First Aid and CPR certificates. Training records were reviewed and staff have required training. Administrator Certificate for Administrator, Richard Pielstick (702666740) Exp 8/26/2024.

Administrator to submit updates of the following documents by 05/12/2024:
LIC 500 Personnel Summary
Copy of Liability Insurance
LIC 9020 Register of Residents
Emergency Disaster Plan (If any changes)
Infection Control Plan (If any changes)

Deficiencies 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. Appeal rights given.

Exit interview was conducted with Administrator and a copy with given. Signature on forms confirms receipt of documents...

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jacqueline Macias	TELEPHONE: (707) 588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/20/2024 05:01 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: 06/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Request Denied

Type B

Section Cited

CCR

87625(b)(3)

Managed Incontinence

(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in that LPAs observed a residents bed sheets to be wet and having an incontinence odor throughout the Memory Care unit which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/05/2024
	Plan of Correction
1 2 3 4	Admin agrees to submit a plan to keep facility free from Incontinence odors and submit to CCL by POC due date of 7/5/24

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jacqueline Macias	TELEPHONE: (707) 588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024

LIC809 (FAS) - (06/04)

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