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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216804022
Report Date: 09/29/2022
Date Signed: 09/30/2022 10:13:06 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
07/27/2022 and conducted by Evaluator Carla Fernandes-Goes
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20220727103847
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
UNANNOUNCEDTIME BEGAN:
01:33 PM
MET WITH:Ric Pielstick TIME COMPLETED:
02:35 PM
ALLEGATION(S):
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Facility is not following resident's care plan.
Facility staff did not respond to resident's alarm.
Facility staff did not dispense resident's medication as prescribed.
INVESTIGATION FINDINGS:
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The Department conducted a complaint investigation regarding the allegation listed above. Licensing Program Analyst Fernandes-Goes arrived unannounced for the purpose of closing the investigation and met with xxxxx.

On August 3rd, 2022, LPA Fernandes-Goes toured the facility; conducted interviews; acquired documentation; and made observations of the facility. During investigation conducted, Department tour facility and made observations, conducted interviews on 8/1/2022, 8/3/2022, 8/8/2022, 9/22/2022, & 9/23/2022; and reviewed documentation submitted.

Continued LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 707-588-5026
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
07/27/2022 and conducted by Evaluator Carla Fernandes-Goes
COMPLAINT CONTROL NUMBER: 21-AS-20220727103847

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
UNANNOUNCEDTIME BEGAN:
01:33 PM
MET WITH:Ric Pielstick - Executive Director TIME COMPLETED:
02:35 PM
ALLEGATION(S):
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Facility staff did not assist resident with hygiene needs.
Facility staff did not ensure resident's bathroom was sanitary.
Facility failed to follow admission agreement.
INVESTIGATION FINDINGS:
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The Department conducted a complaint investigation regarding the allegation listed above. Licensing Program Analyst Fernandes-Goes arrived unannounced for the purpose of closing the investigation and met with Ric Pielstick - Executive Director.

On August 3rd, 2022, LPA Fernandes-Goes toured the facility; conducted interviews; acquired documentation; and made observations of the facility. During investigation conducted, Department tour facility and made observations, conducted interviews on 8/1/2022, 8/3/2022, 8/8/2022, 9/22/2022, & 9/23/2022; and reviewed documentation submitted.

LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 9
Control Number 21-AS-20220727103847
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 09/29/2022
NARRATIVE
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Department has learned that resident’s R1 LIC 602s (physician’s assessment) dated 9/11/2020 & 6/16/2022 states dementia, sundowning & wandering behavior, sleep apnea, able to communicate needs, and able with assistance to do the following bathe self, dress/groom, feed, care for own toileting needs. In addition, care plans 12/15/21 states “requires stand by assistance with s/set up and performance of grooming tasks (28 points); 3 to 4x/week showers (10 points); requires stand by assistance with dressing and undressing 2x/day (31 points)” and care plan 6/13/2022 states “requires stand by assistance with s/set up and performance of grooming tasks (28 points); 1 to 2x/week showers (13 points); requires hands on assistance with dressing and undressing 2x/day (37 points). Department has learned that picture taken by POA on July 19, 2022 shows resident R1 with an extremely red groin rash and stated that resident R1 was being found with same clothes when visiting consecutive days. Facility staff stated, “that resident was refusing showers” and has no shower or changing record logs. In regard to staff not assisting resident with hygiene needs, at this time Department can’t prove or disprove that it has occurred.

In regard to, “Facility staff did not ensure resident's bathroom was sanitary.” Department has learned that facility has the following number of staff in memory care per shift AM 4 care staff & 1 med tech, PM 4 care staff & 1 med tech, and NOC 2 care staff & 1 med tech. According with MC Director Juan Ferrel interview “There is a person designated for housekeeping in Memory Care” which are not caregivers. “Care staff do the bed, light cleaning, and pick up clothes on the floor, make sure that bathrooms are clean. If bathrooms are not clean, they contact housekeeping. Housekeeping change sheets on beds onn the housekeeping days assigned for the room. In the case of an accident care staff will change sheets and placed them to wash. Care staff still does the laundry for residents.” During visit to facility on 8/3/2022, LPA toured the facility and randomly observed bedrooms/bathrooms and found facility clean. There is not sufficient evidence for the Department to prove or disprove that residents bathrooms were not sanitary.

Continued LIC 9099-C
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 707-588-5026
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
LIC9099 (FAS) - (06/04)
Page: 3 of 9
Control Number 21-AS-20220727103847
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 09/29/2022
NARRATIVE
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Department investigated allegation “Facility failed to follow admission agreement”, resident R1 admissions agreement signed on 10/ 2020 states that “b. (pg 9) Amount of Refund - within thirty (30) days after your apartment has been vacated and your property has been removed from it, Oakmont shall pay you or your responsible party a refund of any prorated unused portion of your final monthly fee payment…”. According with records reviewed and interviews, facility provided a refund to resident R1/POA on August 17, 2022. Amount refund was based on care plan, care fees, and rent fees. Based on records reviewed and interviews, Department can not prove or disprove that facility didn’t follow admission agreement at this time.

A finding that the complaint allegations of “Facility staff did not assist resident with hygiene needs.”; “Facility staff did not ensure resident's bathroom was sanitary.”;
“Facility failed to follow admission agreement.” are unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.


No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 707-588-5026
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
LIC9099 (FAS) - (06/04)
Page: 4 of 9
Control Number 21-AS-20220727103847
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
10/13/2022
Section Cited
CCR
87411(a)
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87411(a)Personnel Requirements This requirement isn't met as evidenced by: Based on interviews & records facility didn't comply w/section above resident R1 careplan needs which poses a risk to health,
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Facility to ensure that resident's needs are met accoding to careplan and doctor's orders. Facility agrees to submit Department with a plan on how they will ensure that residents services will be met as needed
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safety, personal rights of resident in care. Department learned that R1 has a care plan dated 12/15/21 & 6/13/22 states breathing treatment needs & fall management plan that were not followed (see LIC 9099)
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and based on docs orders by POC date of 10/13/2022 in order to clear this citation.
Request Denied
Type B
10/13/2022
Section Cited
CCR
87468.1(2)
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87468.1(2) Persoanl Rights This requirement isn't met as evidenced by: Based on interviews & records facility didn't comply w/section above R1 had a fall on an apartment of another resident on 7/22/22
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Facility to ensure that residents are to be accorded safe, healthful and comfortable accommodations, furnishings and equipment. Facility to submit Department w/ self certification that careplans have been
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sensor alsarm record went off 3 different times during PM shift for R1; R1 was found in another resident's room and sent out to ER. Facility was aware resident wakes up and needs to be redirected during the night.(see LIC 9099 and docs)
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reviewed and staff understands/knows residents needs by POC date of 10/13/2022 in order to clear this citation.
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: 09/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 9
Control Number 21-AS-20220727103847
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 09/29/2022
NARRATIVE
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Department has learned that resident R1 was admitted under assisted living in October 2020, however; moved into memory care on July 2021. LIC 602s (physician’s assessment) for resident R1 dated – 9/11/2020 & 6/16/2022 states dementia, sundowning & wandering behavior, sleep apnea, able to communicate needs, and able with assistance to do the following bathe self, dress/groom, feed, care for own toileting needs. In addition, care plans provided by facility states the following:
• Care plan 12/14/20 states requires set up and/or assistance with clothes 1x/day (15 points); breathing treatments – resident requires staff observation and assistance 1 to 2 times per day (8 points) Det up CPAP machine. Machine in night stand and hose in closet. Ensure it is plugged in, nose piece attached to hose and plastic container is filled with water – observe/report breathing treatments. Maintain safe/clean environment.
• Care plan 12/15/21 states requires stand by assistance with s/set up and performance of grooming tasks (28 points); 3 to 4x/week showers (10 points); requires stand by assistance with dressing and undressing 2x/day (31 points); requires a fall management program due to fallen within the past year (16 points); breathing treatments – resident requires staff observation and assistance 1 to 2 times per day (15 points); status checks – resident doesn’t require status checks (0 points)
• Care plan 6/13/2022 states requires stand by assistance with s/set up and performance of grooming tasks (28 points); 1 to 2x/week showers (13 points); requires hands on assistance with dressing and undressing 2x/day (37 points); requires a fall management program due to fallen within the past year (16 points); breathing treatments – resident requires staff observation and assistance 1 to 2 times per day (15 points); status checks – resident doesn’t require status checks (0 points)
According to facility “Instructions” on care plans specified above, Breathing Treatments for care plans 12/15/21 & 6/13/22 – states “Resident requires staff observation and assistance 1 to 2 times per day.” With the following instructions “Assist resident with setting up CPAP machine in the evening around 8:30 – 9pm. This includes filling the cage with water, hooking the hose up, and turning it on.
Continued LIC 9099-C
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 707-588-5026
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
LIC9099 (FAS) - (06/04)
Page: 6 of 9
Control Number 21-AS-20220727103847
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 09/29/2022
NARRATIVE
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 Remove from apartment and clean during the day – store in med room. Resident ‘R1’ has tendency to hide pieces if left in apartment. The PM shift will bring to ‘resident R1’ around bedtime and assist with set up. Overnight shift will need to check in and see that ‘R1’ is still wearing it during the night.” – CPAP discontinued on 6/23/2022 by doctor’s orders.
Furthermore, CPAP discontinued order dated 6/23/22 from resident’s R1 doctor however, POA for resident R1 states that they were never contacted regarding requesting doctor to discontinue this order. Facility only communicated the decision after the fact – emails between facility and family members states family members questioning decision made by facility to fax doctor to discontinue CPAP orders. According to family and POA the doctor that prescribed CPAP was a pulmonologist who had also diagnosed R1 with COPD and sleep apnea. Email from Kathleen O. Acting ED to family members on June 22, 2022 at 4:02 PM state “…we established is that for the next 7 days we will have a companion with ‘R1’ from 8pm-8am. At that time that person will be observing her to see her sleep patterns and to redirect her with her Cpap.” However; facility staff on June 22, 2022 at 5:30 PM faxed R1’s doctor stating “Could you please review the Cpap treatment and possibly “discontinue” or write an alternative treatment?” Family and POA was never informed that doctor had been contacted to discontinue CPAP order. Family wasn’t informed until 6/24/22 that doctor had agreed to discontinue the CPAP.
MARs (Medication Administration Records) show that July there wasn’t an order for CPAP and June 2022 was done until 6/24/22. Facility states that “they are not to help with CPAP and has no policy or procedure for that.” Between June 3rd and June 21st of 2022 resident 14 times did not receive the treatment due to missing parts of the machine in addition of 2 times that resident refused. Doctor’s order for 2/14/2022 and 1/7/2022 states that “breathing machine at bedtime; ensure it is plugged in, nose piece attached to hose and plastic container filled with water and to be kept in medroom.” Based on documentation reviewed, facility failed to follow doctor’s orders and care plan as it was agreed upon and monthly charged.

Continued LIC 9099-C
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 707-588-5026
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
LIC9099 (FAS) - (06/04)
Page: 7 of 9
Control Number 21-AS-20220727103847
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 09/29/2022
NARRATIVE
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Moreover, Resident R1 had a fall in an apartment for another resident on 7/22/2022 – per facility interviews around 11:30 PM – per sensor alarm record log resident’s R1 sensor went of on 7/22/22 at 9:01 PM, 9:09 PM, and 10:44 PM. Facility stated that resident R1 was found at resident’s R2 apartment around 11:30 PM on 7/22/22 – Resident’s R2 sensor alarm went off on 7/22/22 at 8:11 PM, 8:29 PM, 9:15 PM, 9:33 PM, and 9:50 PM according with record log provided by the facility. ED stated that “Since Nov/Dec of 2021, the system has been on 24/7” According with care plan 12/15/2021 & 6/13/2022, facility was aware that “Resident wakes up on some nights but is easily redirected back to bed after ADL needs are met”, “Resident wanders only within the common areas of the secured community”, and “Resident has fallen within the past year and requires a fall management program”; however, facility staff failed to respond when motion sensor went off and resident R1 wandered into another residents room and had a fall.

According with complaint allegations “Facility is not following resident's care plan.”; “Facility staff did not respond to resident's alarm.”; and “Facility staff did not dispense resident's medication as prescribed.” there were related observations made during visit. Based on LPAs' observations and interviews which were conducted and documentation reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

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.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 707-588-5026
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
LIC9099 (FAS) - (06/04)
Page: 8 of 9
Control Number 21-AS-20220727103847
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
10/13/2022
Section Cited
CCR
87465(c)(2)
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87465(c)(2) Incidental Medical and Dental Care. This requirement is not met as evidenced by: Based on interviews, record reviews,facility didn't comply w/section above in 1 out 1 resident which poses a potential risk to resident in care.
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Facility to submit Department with self certification that all residents under care will have their doctor's orders followed as prescribed and that staff understand these orders by POC due date of 10/13/2022.
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Resident R1 care plan 6/13/22 requires breathing treatments according with doctor's orders. However, MARs show that between Junde 3 & June 21/2022 resident R1 14 x din't receive treatment due to missing parts of a machine(see9099,docs
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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: 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
LIC9099 (FAS) - (06/04)
Page: 9 of 9