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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804022
Report Date: 10/20/2022
Date Signed: 10/20/2022 04:45:09 PM


Document Has Been Signed on 10/20/2022 04:45 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: 91DATE:
10/20/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Ric Pielstick, Executive DirectorTIME COMPLETED:
04:55 PM
NARRATIVE
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LIcensing Program Analyst (LPA) Jill Nakagawa arrived at 1:00 PM and conducted an unannounced random required non-compliance inspection of the facility. LPA met with Executive Director Ric Pielstick. LPA toured the building and grounds with Executive Director and found the facility to be clean and in good repair.

LPA did a room inspection of the Traditions/Memory Care Unit and found all the bathrooms were equipped with necessary grab bars and non-slip floors/mats. Residents were eating lunch in the dining room, with care staff and servers attending the residents with their meals.

LPA reviewed 6 resident records (R1 -R6) which showed that 4 out of 6 residents' 602's were not complete, so Medical Assessments will need to be completed as stated on attached 809-D At the time of inspection Medications were stored and locked at all times. There have been no medication errors since the NCC of 6/14/2022. There were no residents with any Prohibited Conditions at the time of inspection. Resident Records were reviewed and appeared to be in order. At the time of inspection staffing in Memory Care currently has 4 care staff and 1 med tech, along with dining staff helping with meal service but not care. LPA requested Memory Care Schedule for the last 3 months. Food Service was inspected and LPA found that perishable foods were stored in covered containers, and the refrigerator and freezer were at a temperature within regulation. LPA requested proof of staff training by certified staff on food handling and storing.

The following deficiency were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6, Ch. 8 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: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2022
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 10/20/2022 04:45 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: 10/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
10/20/2022
Section Cited

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87458(a) Medical Assessment. Prior to accepting a person as a resident the licensee must obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. ** This requirement was not met. Based on LPAs record review
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he facility failed to ensure Residents (R1-4) had submitted a completed medical assessment, within the last year. R1 -R4 did not sign Physician's Report which poses a potential health and safety risk to residents in care.
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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 MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2022
LIC809 (FAS) - (06/04)
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