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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803998
Report Date: 07/17/2025
Date Signed: 07/17/2025 03:20:02 PM

Document Has Been Signed on 07/17/2025 03:20 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/
DIRECTOR:		TRISTAN AMARIFACILITY TYPE:
740
ADDRESS:301 WHITE OAK DRIVETELEPHONE:
(707) 538-1914
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY: 79CENSUS: 62DATE:
07/17/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:14 AM
MET WITH:Tristan Amari, Business Office ManagerTIME VISIT/
INSPECTION COMPLETED:
03:34 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced, to conduct a Case Management visit. LPA was greeted by concierge. Tristan Amari, Business Office Manager arrived later.

On 7/10/25 CCL received an Incident Report indicating that facility had experienced a medication error for seven [7] residents on Monday, 7/7/25 (deficiency cited, see 809D). Later the same day, CCL received another Incident Report indicating a resident (R8) may have also received the wrong medication on 7/7/25.

LPA interviewed Health and Wellness Director (HWD) Jody Livingston and Health Services Assistant (HSA) Pam Brown about medication errors that occurred on 7/7/25.

Per HWD and HSA, the medications errors occurred due to Med Techs pre-pouring medication. As pertains to this incident there were two instances of pre-pouring (deficiency cited, see 809D). On the morning of 7/6/25, staff (S1) pre-poured medications to be administered on the morning of 7/7/25. On the evening of 7/6/25, staff (S2) pre-poured medications to be administered the evening of 7/7/25. The two [2] boxes of pre-poured medications were then placed in the medication closet, to be administered the next day. On the morning of 7/7/25, staff (S3) mistakenly pulled the evening medication box and administered evening medications to residents R1, R2, R3, R4, R5, R6, and R7. Later in the morning of 7/7/25, HSA was notified that resident R8 was not given her medications at all that morning. HSA then went to R8's room and administered their morning medications. So, R8 did receive her morning medications on the morning of 7/7/25; thereby receiving them at approximately 10:30am instead of at 8:00am as scheduled.

Continued on 809C...

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/17/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 07/17/2025
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Continued from 809C...

Per incident report and submission of proof of notification to LPA, HWD notified each respective residents' primary care physician, via fax of respective residents' medication error. HWD notified respective residents' responsible parties via telephone. LPA advised going forward, facility to ensure responsible parties are notified in writing in addition to via telephone.

Per HWD and HSA, pre-pouring as been an on-going issue with facility Med Techs. HWD knows that regulation states that each resident's medication shall be stored in its originally received container and no medications shall be transferred between containers. HWD advised LPA they stress to staff not to pre-pour medications, but that some Med Techs report pre-pouring to be much easier than live pouring.

HWD advised LPA that S3 is currently on suspension and will be terminated. HWD advised LPA that additional Relias training will be conducted with all direct care staff that administer medication. In order to stress the importance of live pouring, HWD and HSA will formulate a Med Tech test based on training requirements specified in Health and Safety Code (HSC)1569.69(a)(5) for all Med Techs. HWD will send copy of prospective test to CCL before administering test to ensure compliance with HSC.

Additionally, HWD and HSA have scheduled a staff meeting to address pre-pouring. HWD will address the pre-pouring by eliminating the medication boxes in which the medications are pre-poured, thereby eliminating the ability to pre-pour. Per HSA, HSA will be auditing medication room closet and medication cart to see if they find any pre-pouring. The audit will occur daily and randomly anywhere between 9:00am and 5:30pm, which covers both shifts on which medications are administered. If HSA finds instances of pre-pouring, identified staff will immediately be given a write up that is last and final. Additionally, identified staff would face discipline up to and including termination. HWD advised LPA, facility is going to re-educate staff on the logistics of giving medications, such as reviewing proper medication cart placement and procedures.

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 BOM. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

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

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/17/2025 03:20 PM - It Cannot Be Edited


Created By: Christi Coppo On 07/17/2025 at 02:33 PM
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: 07/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/18/2025
Section Cited
CCR
87465(h)(5)

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87465 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.
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Facility to submit plan to conduct in-service training on pre-pouring medication by plan of correction due date. In-service training to be coinducted no later than 8/7/25. Additinally, facility to submit written procedure plan to coinduct daily
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This requirement not met by licensee as evidenced by: Based on LPA and HWD interview, staff are pre-pouring medications, resulting in medication errors, which poses an immediate health, safety or personal rights risk to persons in care.
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 audit of meication closet and medication cart to ensure staff are not pre-pouring medications, by no later than 8/7/25.
Type A
07/17/2025
Section Cited
CCR87465(a)(4)

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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed...(4) The licensee shall assist residents with self-administered medications as needed. This requirement not met by licensee as evidenced by: residents R1, R2, R3, R4, R5, R6, and R7 were
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Facility to submit plan to conduct medication training via their chosen vendor, Relias by plan of correction due date. Training to be completed by all staff administering medications by no later than 8/7/25.
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 each administered the wrong medication, which poses an immediate health, safety or personal rights risk to persons 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.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2025


LIC809 (FAS) - (06/04)
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