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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803601
Report Date: 08/06/2021
Date Signed: 08/06/2021 09:38:35 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/02/2021 and conducted by Evaluator Erik Gonzalez Campos
COMPLAINT CONTROL NUMBER: 21-AS-20210702113443
FACILITY NAME:OAKMONT GARDENSFACILITY NUMBER:
496803601
ADMINISTRATOR:DEL DOSSO, MELISSAFACILITY TYPE:
740
ADDRESS:301 WHITE OAK DRTELEPHONE:
(707) 538-1914
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY:79CENSUS: 37DATE:
08/06/2021
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Executive Director, John BeltzTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Staff member handled resident in an aggressive manner.
Staff member spoke to resident in an aggressive manner.
INVESTIGATION FINDINGS:
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Licensing program analysts (LPA), Erik Gonzalez Campos and Farhaan Sarangi conducted a complaint investigation and met with Executive Director, John Beltz to deliver complaint findings. LPA conducted interviews with staff and witnesses. Facility and law enforcement records were received and reviewed.

LPA has determined that on 6/28/2021, Staff (S1) grabbed Resident (R1’s) pendant on R1’s neck and stated “stop pushing it”. The incident was witnessed by facility staff. Facility took disciplinary action and terminated S1. Based on interviews with staff and review of evidence gathered the allegation is substantiated.

The preponderance of evidence standard has been met, therefore the allegations Staff member handled resident in an aggressive manner and staff member spoke to resident in an aggressive manner are found to be SUBSTANTIATED. California Code of Regulations, Title 22 are being cited on the attached LIC9099D.
Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Appeal rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 21-AS-20210702113443
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: OAKMONT GARDENS
FACILITY NUMBER: 496803601
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/06/2021
Section Cited
CCR
87468.1(a)
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Personal Rights of Residents in All Facilities - Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
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Licensee to ensure further training on personal rights. POC Due 08/13/2021. Furthermore S1 has been terminated.
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This requirement is not met as evidenced by: Based on record review and interviews the licensee did not ensure that personal rights of Resident (R1) was accorded when witnesses observed resident being handled/spoke to resident in an aggressive manner by staff (S1) which is an immediate risk to the personal rights of 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: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2