496803998-1-11-2024-21-AS-CCOO-CZE4FE-20240111180349

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803998
Report Date: 01/11/2024
Date Signed: 01/11/2024 06:04:03 PM

Document Has Been Signed on 01/11/2024 06:04 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 GARDENS		FACILITY NUMBER:	496803998
ADMINISTRATOR:	SORIANO, MARIELE		FACILITY TYPE:	740
ADDRESS:	301 WHITE OAK DRIVE		TELEPHONE:	(707) 921-1861
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95409
CAPACITY:	79	CENSUS: 45	DATE:	01/11/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	Morgan Holien, Executive Director		TIME COMPLETED:	06:18 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Christi Coppo conducted an unannounced Required - 1 Year annual inspection and met with Executive Director, Morgan Holien. There are currently 45 residents living in the Assisted Living (AL) portion of the facility and 113 residents living in the Independent Living (IL) portion of the community. There are no residents with a diagnosis of dementia and one resident receiving hospice care at the time of the visit. Required postings were observed. Facility contact information was reviewed. Fees are current at the time of visit. Beginning at 9:15 AM, LPA and ED toured assisted living portion of the community including activity rooms, grounds and kitchen (located in the assisted living). All interior parts of the facility were found to be a comfortable temperature. Exits and pathways were free from obstructions. Hot water temperature measured 117.7 F and 112.8 F, respectively, in faucets used by residents which is within regulation of 105 to 120 degrees F. LPA observed at least a minimum of a 2 day supply of perishable and 7 day supply of non-perishable food quantity and quality stored in a safe manner for residents in care and staff as well as an emergency food supply. Meals are prepared in the main kitchen and brought to the dining room in the AL portion of the community for residents living there. LPA observed toxins in unlocked cabinet in ancillary Assisted Living Dining room. Per Title 22 regulation 87309 (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients (deficiency cited, see 809D). Fire extinguishers were current and charged as of December 4, 2023. Fire alarm system was tested and inspected; documentation of last inspection conducted on 10/17/2023 provided and documentation of sprinklers serviced on 6/19/2023 provided. A disaster drill was conducted on December 1, 2023.At approximately 12:30pm LPA and ED toured resident rooms and LPA interviewed residents. Continued on LIC809C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

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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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: 01/11/2024

NARRATIVE

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Continued from 809...

Currently, facility does not have a qualified certified Administrator. Per Title 22 regulation 87405(a) Administrator - Qualifications and Duties(a)All facilities shall have a qualified and currently certified administrator (deficiency cited, see 809D). CCL has been corresponding with ED about issue of facility not having a qualified certified Administrator. Facility cited for deficiency of regulation 87405(a) on 11/03/2023. On 12/22/2023 LPA emailed ED to advise document submitted to CCL on 12/18/2023 does not specifically address how proposed Administrator will meet regulation 87405 Administrator Qualifications and Duties while working eight [8] in-person hours per week as identified in the submitted LIC500 Personnel Record. Also, CCL has not received requested Board Resolution Statement, designating an Administrator. Both aforementioned items were required to be submitted to CCL as agreed upon per CCL’s case management visit on 12/12/2023.

Additionally, on 12/28/2023 CCL LPM emailed ED and requested that they resend the documents they previously sent to AdminCertInfo@dss.ca.gov as they were unable to find a record of ED’s certification (Cert. #6064643740). CCL did not receive a response from ED. On 1/10/2024 LPM emailed ED informing ED that CCL has not received a response to LPM’s request on 12/28/2023. Also, LPM advised ED that as of 1/10/2024 the ED is not on the Pending Administrator list. LPM requested ED provide an update regarding the aforementioned by the end of the day. No response received.

LPA will return at a later to complete annual inspection.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview was conducted with Executive Director and a copy of the report was given.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/11/2024 06:04 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: 01/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87405(a)

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. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, interview, and record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/12/2024
	Plan of Correction
1 2 3 4	Facility to provide plan that specifically addresses how proposed Administrator will meet regulation 87405 Administrator Qualifications and Duties while working eight [8] in-person hours per week as identified in the submitted LIC500 and/or Facility will submit current Adminstrator certificate for ED, Morgan Holien. The aforemtioned documention to be submitted to CCL by plan of correction due date of 1/12/2024. Failure to comply with POC may result in further action.

Type A

Section Cited

CCR

87309

87309 (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above as toxins accessible to residents in Ancillary Assisted Living Dining Area. Toxins stored in cabinet under/around sink area was not locked. which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/12/2024
	Plan of Correction
1 2 3 4	ED to submit plan of how facility will train employees to keep all toxins locked. Once training is completed ED will submit LIC9098 showing completed staff training. ED to complete staff training and submit LIC9098 by 1/18/2024

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 Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/18/2024 12:47 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 01/16/2024 04:04 PM

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: 01/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87455(c)(3)(B)

87455 Acceptance and Retention Limitations (c) No resident shall be accepted or retained if any of the following apply: (3) The resident's primary need for care and supervision results from…: B) Dementia, unless the requirements of Section 87705, Care of Persons with Dementia, are met. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA record review, the licensee did not comply with the section cited above in [1] out of [1] residents. R4 has DX of dementia but facility does not retain residents with dementia and facility does not have a current exception on file to retain resident with DX of demntia, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/29/2024
	Plan of Correction
1 2 3 4	Facility to submit exception request to retain resident R4 with dementia by plan of correction due date of 1/29/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

LIC809 (FAS) - (06/04)

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