216804022-8-29-2024-21-AS-VBEI-D6ST6C-20240702142655

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216804022
Report Date: 06/20/2024
Date Signed: 08/29/2024 12:46:43 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
04/15/2024 and conducted by Evaluator Helena Rummonds

COMPLAINT CONTROL NUMBER: 21-AS-20240415153642

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
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Executive Director, Ric Pielstick		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff abused resident in care

******** This is an amended version of the original document*******

INVESTIGATION FINDINGS:

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At approximately 1:50PM, Licensing Program Analysts (LPAs) Helena Rummonds and Jacky Macias arrived unannounced to deliver findings regarding the above allegation and met with Executive Director, Ric Pielstick.

Complaint alleges that staff abused resident in care. Per interviews and review of documentation, multiple facility staff reported to facility management on 4/12/2024 that they had witnessed Staff 1 (S1) physically abuse multiple residents in care over the previous two weeks. Abuse included, but not limited to, physically striking resident(s), with their hand or an object, grabbing a resident by the wrists and shaking them, holding a resident down by their neck and transferring a resident roughly. S1 was arrested and the Department issued an immediate exclusion order for S1 on April 23, 2024. Based on information obtained during the investigation, facility staff did not fulfill their mandated reporting requirements.

Continued on 9099(C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5057
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.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 21-AS-20240415153642

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 LIC9099

Based on interviews conducted, documents reviewed, and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiencies are cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Helena Rummonds	TELEPHONE: (707) 588-5057
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

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20240415153642

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 06/21/2024 Section Cited CCR 87468.2(a)(8)	1 2 3 4 5 6 7	87468.2...Personal Rights..(a)...residents in... residential care facilities for the elderly shall have...following personal rights:(8)To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse.	1 2 3 4 5 6 7	Licensee agrees to submit proof of mandated reporting training completed by all staff. Proof of training to conisist of staff names, dates, topics covered, who conducted the training, etc.
	8 9 10 11 12 13 14	Based on document review and interviews conducted, the licensee did not comply with the section cited above by S1 physically abusing multiple residents in care.	8 9 10 11 12 13 14
CCR	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: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Helena Rummonds	TELEPHONE: (707) 588-5057
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

LIC9099 (FAS) - (06/04)

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