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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803998
Report Date: 01/18/2024
Date Signed: 01/18/2024 12:43:51 PM

Document Has Been Signed on 01/18/2024 12:43 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: 45DATE:
01/18/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Morgan Holien, Executive DirectorTIME COMPLETED:
12:52 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to continue the required Annual inspection and was greeted by Morgan Holien, Executive Director (ED). Facility currently has one resident on hospice.

During initial annual inspection on 1/11/2024, LPA initiated file review at 3:00pm. LPA reviewed 5 resident files. Per LPA interview with ED and HWD, one resident is currently on hospice. Per LPA interview with HWD, facility does not have hospice care plan for R1. Per Title 22 regulation 87633(a)(4) Hospice Care of Terminally Ill Residents (a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility when all of the following conditions are met:(4) A written hospice care plan which specifies the care, services, and necessary medical intervention related to the terminal illness as necessary to supplement the care and supervision provided by the facility is developed ...prior to the initiation of hospice services in the facility for that resident, and all hospice care plans are fully implemented by the licensee and by the hospice(s) (deficiency cited, see 809D).

During initial annual inspection on 1/11/2024, LPA reviewed resident files at 3:30pm. LIC602 for R4 shows a DX of dementia; however, it has not been updated since 2021. Per Title 22 regulation 87705(c)(5) Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs (deficiency cited, see 809D). Additionally, the facility does not currently retain residents with DX of dementia. Per Title 22 regulation 87455(c)(3)(B) 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 (deficiency cited, see 809D). Note: 809D final printed on 1/11/2024 amended to capture signature.

Continued on 809C...

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: 01/18/2024
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Continued from 809...

During initial annual inspection on 1/11/2024, at approximately 1:00pm, LPA observed medications to be centrally stored in a locked room in the assisted living building. Per LPA interview with Director of Health and Wellness (DHW) and Med Tech (S1) facility currently using an e-mar, maintaining Centrally Stored Medication Logs, and pre-pouring medications. LPA advised DHW per Title 22 regulation 87465(h)(5) Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers (deficiency cited, see 809D).

LPA and S1 conducted spot check of medications. LPA and S1 reviewed medications for resident R2. LPA and S1 observed resident R2 to have 2 missed doses of Acetaminophen 325mg, Amlodipine 2.5 mg, and Furosemide 20 mg. Doses present in bubble packs, but documented as given to R2. LPA and S1 reviewed missed doses with DHW. LPA advised DHW per Title 22 regulation 87465(a)(4) Incidental Medical and Dental Care - The licensee shall assist residents with self-administered medications as needed (deficiency cited, see 809D).

On 1/18/2024 at approximately 9:30am LPA reviewed staff files. Five [5] out of five [5] staff files either were missing the training log entirely, or the training log present did not show the number of training hours completed. Per Title 22 regulation 87412(c) Personnel Records (c) Licensees shall maintain in the personnel records verification of required staff training and orientation (2) Documentation of staff training shall include (D) Number of training hours per subject (deficiency cited, see 809D).



Civil Penalty in the amount of $600 is being assessed for failure to correct deficiency 87405(a) cited on 1/11/2024 with plan of correction due date of 1/12/2024. CCL may assess $100 per day until deficiency is cleared and plan of correction is satisfied.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: Evidence of Liability Insurance and Plan of Operation.

Continued on 809C(2)...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024
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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: 01/18/2024
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Continued from 809C...

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

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

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/18/2024 12:43 PM - It Cannot Be Edited


Created By: Christi Coppo On 01/18/2024 at 11:22 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: OAKMONT GARDENS
FACILITY NUMBER: 496803998

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA, HWD, and Med Tech observation and record review, resident R2 missed two [2] doses of Acetaminophen 325mg, Amlodipine 2.5 mg, and Furosemide 20 mg, respectively. Doses present in bubble packs, but documented as given to R2. Therefore, the licensee did not comply with the section cited above in [1] out of [5] residents reviewed which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/05/2024
Plan of Correction
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Facility to submit LIC9098 self-certifying facility conducted staff training on how to properly assist residents with self-administered medication. In addition to LIC9098, facility to submit training record showing name of trainer(s), number of hours of training, and name of training course completed, signed by all required attendees. Training record and LIC9098 due by plan of correction due date 02/05/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 Moellers
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 01/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2024


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Document Has Been Signed on 01/18/2024 12:43 PM - It Cannot Be Edited


Created By: Christi Coppo On 01/18/2024 at 11:22 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: OAKMONT GARDENS
FACILITY NUMBER: 496803998

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(c)(2)(D)
Personnel Records
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. (2) Documentation of staff training shall include: (D) Number of training hours per subject.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and record review, as well as interview with ED, the licensee did not comply with the section cited above in [5] out of [5] staff files reviewed. Five [5] out of five [5] staff files either were missing the training log entirely, or the training log present did not show the number of training hours completed, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/29/2024
Plan of Correction
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Facility to submit plan of how, going forward, facility will ensure all required staff complete training requirements per regulation 87412(c), as well as how facility will maintain documentation of staff training as required and outlined per regulation 87412(c) by plan of correction due date 1/29/2024.
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA interview with HWD and Med Tech, the licensee did not comply with the section cited above as facility is currently pre-pouring medications, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/29/2024
Plan of Correction
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Facility to submit LIC9098 self-certifying facility has immediately stopped pre-pouring medications as well as submit a plan of how facility will deliver medications to residents by live-pouring.
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
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 01/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2024


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 01/18/2024 12:43 PM - It Cannot Be Edited


Created By: Christi Coppo On 01/18/2024 at 11:22 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: OAKMONT GARDENS
FACILITY NUMBER: 496803998

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87633(a)(4)
Hospice Care for Terminally Ill Residents
(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility, when all of the following conditions are met: (4) A written hospice care plan which specifies the care, services, and necessary medical intervention related to the terminal illness as necessary to supplement the care and supervision provided by the facility is developed for each terminally ill resident or prospective resident by that resident's hospice agency and agreed to by the licensee and the resident, or prospective resident, or the resident's or prospective resident's Health Care Surrogate Decision Maker, if any, prior to the initiation of hospice services in the facility for that resident, and all hospice care plans are fully implemented by the licensee and by the hospice(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and record review, as well as interview with HWD, the licensee did not comply with the section cited above in [1] out of [1] resident (R1) on hospice. R1 has been on hospice beginning 11/20/2023 but did not have a Hospice care plan on file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/18/2024
Plan of Correction
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On initial annual inspection conducted on 1/11/2024, facility did not have hospice care plan for R1. On 1/12/2024 facility received hospice care plan for R1 and provided to CCL. Deficeincy cleared.

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
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 01/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2024


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 01/18/2024 12:43 PM - It Cannot Be Edited


Created By: Christi Coppo On 01/18/2024 at 11:22 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: OAKMONT GARDENS
FACILITY NUMBER: 496803998

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observation and record review, the licensee did not comply with the section cited above in [1] out of [1] resident (R4) with a diagnosis of dementia, LIC602 Physican's Report for R4 dated 2021,which poses a potential health, safety or personal rights risk to person in care.
POC Due Date: 02/05/2024
Plan of Correction
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2
3
4
Facility to submit to CCL current LIC602 for R4 by plan of correction due date of 2/05/2024.
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
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 01/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2024


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