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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803998
Report Date: 11/03/2023
Date Signed: 11/03/2023 04:15:11 PM


Document Has Been Signed on 11/03/2023 04:15 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:OAKMONT GARDENSFACILITY NUMBER:
496803998
ADMINISTRATOR:SORIANO, MARIELEFACILITY TYPE:
740
ADDRESS:301 WHITE OAK DRIVETELEPHONE:
(707) 921-1861
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY:79CENSUS: 50DATE:
11/03/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Executive Director Morgan HolienTIME COMPLETED:
04:29 PM
NARRATIVE
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At approximately 8:40pm LPA Christi Coppo arrived unannounced to conduct a case management regarding Incident Report received on 10/24/2023. LPA met with Executive Director, Morgan Holien and requested resident's records to review.

Per facility’s Incident Report: On 10/22/2023 at approximately 7:30am, the resident (R1) was returned to the facility by their son. The facility thinks that perhaps R1 left through their patio door. The patio door opens to the unsecured facility parking lot. The facility thinks that perhaps R1 walked over to a friend’s house and slept in their backyard. R1 woke up in the friend’s backyard on 10/23/2023 and then walked back to their son’s house. Facility thinks that R1 had experienced a fall at some point during their elopement because they had noticeable bruising on their head and a scraped area on their leg. Facility gave R1 a shower and dressed their scraped leg. Facility also put hourly resident checks in place when overnight caregiver or family is not present.

At approximately 9:50am LPA met with Health and Wellness Director (HWD) Jody Livingston. HWD indicated that R1 moved into facility on 10/13/2023, not 09/30/2023 as reported on Incident Report indicated. Facility was advised by R1's son that R1 had a caregiver that will be with him 24 hours per day, one from 8:00am-8:00pm, and another from 8:00pm to 8:00am. Caregiver was placed by First Light Home Care (Director Maria Mann 707-501-9830). Per HWD, the family canceled the caregiver on 10/22/2023 but did not notify facility staff of cancelation. Per HWD, as a result of being informed that R1 had a caregiver, staff were not instructed to check on resident during the time frame of 8:00pm on 10/22/2023 to 7:30am on 10/23/2023. Therefore, no one at the facility realized the resident was gone until the resident's son brought the resident back to the facility at approximately 7:30am on 10/23/2023.

At approximately 10:50am LPA reviewed R1’s LIC602 and observed the following: R1 has a diagnosis of Mild Cognitive Impairment with hypertension and coronary artery disease. R1 was not known to have wandering behavior or sundowning behavior, R1 is not able to leave the facility unassisted.

Per HWD, on 10/24/2023 the resident's PCP came to facility to evaluate R1. Based upon evaluation, R1 had a medication added to address his Major Depressive Disorder. LPA reviewed e-Mar and confirmed addition of new medication. Per HWD, as of 10/24/2023, a private pay caregiver has resumed attending to R1 from 8:00pm-8:00am. Facility produced Hourly Status Check log indicating hourly staff check of R1, beginning 10/23/2023 at 9:00pm to address wandering behavior. At approximately 12:45pm LPA reviewed R1's updated Care Plan and confirmed that facility updated resident's Care Plan to monitor resident for wandering and/or elopement behavior. Per LPA interview with HWD, hourly monitoring of R1 will take place 4 times per AM and PM shift and 2 times per NOC shift. HWD agrees to update care plan with frequency of hourly checks.

Continued on 809C....

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 GARDENS
FACILITY NUMBER: 496803998
VISIT DATE: 11/03/2023
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continued from 809...

LPA reviewed R1's intake Appraisal/Evaluation. R1's intake indicated he has a stage 3 or 4 pressure wound at time of admission. Intake completed by Health and Wellness Director (HWD) Jody Livingston on 9/29/2023. Per LPA interview HWD, the indication of a stage 3 or 4 pressure wound was a clerical error. LPA received signed statement from HWD indicating R1 was not admitted with a stage 3 or 4 pressure wound, nor does he have a stage 3 or 4 pressure wound currently.

Per LPA's observation of DOJ database inquiry, current Executive Director Morgan Holien does not have fingerprint clearance as required per Title 22 regulation 87355(d). ED understands they must have fingerprint clearance in order to work at the facility. ED agrees to cease working at the facility until fingerprint clearance is obtained, not just applied for. ED is not associated to the facility either. ED agrees that they will pursue association to the facility before returning to facility. ED verifies that since 02/06/2023 she has been acting as Executive Director and pursuing Administrator certification and verifies that they corresponded about the process of submitting the application for Administrator certification with CCL LPA via email.

Per ED, facility does not have a currently qualified and certified administrator. Facility to submit written plan indicating plan for implementation and start date of qualified and certified administrator. Plan to be submitted to CCL LPA by POC due date of 11/06/2023

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Executive Director and a copy of this report was given.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/03/2023 04:15 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: OAKMONT GARDENS

FACILITY NUMBER: 496803998

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/06/2023
Section Cited
CCR
87355(d)

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Criminal Record Clearance (d) All individuals subject to criminal record review shall be fingerprinted. Licensee did not meet this requirement as evidenced by; based on DOJ database report, Executive Director does not have fingerprint clearance.
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Executive Director to submit proof of correction indicating she will not be present or working at the facility, and will not return to the facility until after she has: obtained DOJ fingerprint clearance, is associated to facility, and submited proof of required clearance and association to CCL.
Type A
11/06/2023
Section Cited
CCR
87411(a)

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Personnel Requirements – General(a)Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Licensee did not meet this requirement as evidenced by; elopement of resident. This poses an immediate Health, Safety or Personal rights risk to residents.
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Facility agrees hourly checks of R1 will be increased to 4 times per AM and PM shift, and 2 times per NOC shift. Facility agrees to update care plan with frequency of hourly checks and submit to CCL LPA by POC due date of 11/06/2023
Type A
11/06/2023
Section Cited
CCR87405(a)

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Administrator - Qualifications and Duties(a)All facilities shall have a qualified and currently certified administrator. Licensee did not meet this requirement as evidenced by; LPA interview with ED and record review, facility does not have a currently qualified and certified administrator. This poses an immediate Health, Safety or Personal rights risk to residents.
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Facility to submit written plan indicating plan for implementation and start date of qualified and certified administrator. Plan to be submitted to CCL LPA by POC due date of 11/06/2023

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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: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2023
LIC809 (FAS) - (06/04)
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