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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804022
Report Date: 11/14/2024
Date Signed: 11/14/2024 11:52:23 AM

Document Has Been Signed on 11/14/2024 11:52 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:OAKMONT OF NOVATOFACILITY NUMBER:
216804022
ADMINISTRATOR/
DIRECTOR:		PINKNEY, KIMARIFACILITY TYPE:
740
ADDRESS:1465 S. NOVATO BLVD.TELEPHONE:
(628) 215-1200
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY: 118CENSUS: 74DATE:
11/14/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Kimari Pinkney - Administrator
Scott Davis - Executive Director		TIME VISIT/
INSPECTION COMPLETED:
12:05 PM
NARRATIVE
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At approximately 10:00 am, Licensing Program Analysts (LPAs) Loera and Leibert arrived unannounced to conduct a Case Management - Incident Visit and met with Administrator Kimari Pinkney. The purpose of the visit was to follow up on self-reported incident that were submitted to Community Care Licensing (CCL).

Incident Report: CCL received an incident report on 10/17/2024. Report states on 10/11/2024, R1 had eloped. R1 went out for a walk with a companion and was dropped off back to the community inside the lobby around 2:00 pm but was not checked in. Around 2:15 pm, R1 was unable to be located by staff. Staff were alerted and began searching the property and beyond. At 2:28 pm R1 was located behind in the community at a neighborhood park where R1's companion typically walks R1. There were no injuries and R1 was transported back to the community. (Deficiency Cited)


See LIC809-D for Deficiency. Exit interview conducted with Administrator and a copy of this report was provided.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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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Document Has Been Signed on 11/14/2024 11:52 AM - It Cannot Be Edited


Created By: Anthony Loera On 11/14/2024 at 11:01 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: 11/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
11/14/2024
Section Cited
CCR
87411(a)

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87411(a) Personal Requirements - General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidence by:
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Cleared at time of visit. Facility conducted an in-service training about elopement procedures and has been completed for all staff in the community.
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Based on incident report and interview, facility failed to provide supervision to R1 resulting in an elopement. The absense of supervision is an immediate risk to the Health, Safety and Rights of resident in care.***A Civil Penalty of $500.00 is being assessed.
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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:Kimberley Mota
LICENSING EVALUATOR NAME:Anthony Loera
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


LIC809 (FAS) - (06/04)
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