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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804022
Report Date: 08/03/2022
Date Signed: 08/03/2022 03:31:28 PM


Document Has Been Signed on 08/03/2022 03:31 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
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: 80DATE:
08/03/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Ric Pielstick - Executive DirectorTIME COMPLETED:
03:31 PM
NARRATIVE
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Licensing Program Analyst (LPA) Fernandes-Goes arrived to conduct a case management visit regarding incident report submitted to Community Care Licensing (CCL) for resident R1 which occurred on 7/30/2022. LPA met with Ric Pielstick - ED.

Per facility resident R1 AWOL/eloped while under facility responsibility. Resident R1 has a physician's report dated 6/8/2022 diagnostic of dementia and states that resident is NOT able to leave facility unassisted at any time. Resident R1 lives in the assisted living part of facility. Per facility staff resident R1 had her wander guard self removed and walked out of the facility and was found by staff at Grocery Outlet. (see confidential name list, copies, LIC 809-D)

Since this incident, facility has reassessed resident R1; discussed plan of care with family; conducted staff in-service for elopement and facility elopement policy and procedure which have been handled to the Department as prove of correction; and elopement drill has been scheduled. (copy on file) Resident R1 will be moving out of the community. At this time resident has escort service and every 2 hrs. check.


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. Appeal of Rights Given.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2022
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 08/03/2022 03:31 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
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: 08/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/04/2022
Section Cited

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87705(b)(2)Care of Persons with Dementia - Safety measures to address behaviors such as wandering.This requirement isn't met as evidenced by:Based on interviews,SIR & physician's report R1 eleoped w/out staff
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knowledge on 7/30/22 the facility didn't comply w/section above to address behaviors such as wandering for resident R1 which poses an immediate Health, Safety risk to residents in care. (see copies)
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POC cleared

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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 MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2022
LIC809 (FAS) - (06/04)
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