Inspection Report Summary
Most inspections found deficiencies related primarily to resident care, medication management, staffing in the memory care unit, and timely reporting of incidents. Several complaint investigations were unsubstantiated, though some substantiated findings included failure to report suspected abuse promptly, inadequate supervision leading to resident elopements, and violations of residents’ personal rights such as improper notification and unauthorized vaccinations. The facility faced civil penalties including a $400 fine for fingerprinting violations and had multiple immediate risk citations over time, but no license suspensions or revocations were noted. The most recent report from April 16, 2025, cited deficiencies for staff lacking current First Aid and CPR certification and incomplete physician reports, indicating ongoing areas needing attention. While some improvements occurred, such as better food quality and staff retraining, the facility continues to have recurring issues with staff training, supervision, and documentation.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
10 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
150% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
78% occupied
Based on a April 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Census: 92
Capacity: 118
Deficiencies: 2
Date: Apr 16, 2025
Visit Reason
An unannounced Annual Required – 1 year inspection visit was conducted to evaluate compliance with licensing requirements including emergency disaster plan, infection control, staff training, and facility conditions.
Findings
The facility was generally found to be in compliance with emergency and infection control plans, food safety, and facility maintenance. However, deficiencies were cited for 7 out of 8 staff members lacking current First Aid and CPR certification, posing an immediate risk to residents.
Deficiencies (2)
7 out of 8 staff members did not have current first aid and CPR certification on file.
2 out of 8 resident records need an updated LIC602 (physician's report).
Report Facts
Residents in care: 92
Total licensed capacity: 118
Resident records reviewed: 8
Staff records reviewed: 8
Staff without current First Aid & CPR certification: 7
Food supply: 2
Food supply: 7
Water temperature range: 110.8-114.4
Fire extinguisher last inspection: 2024
Last emergency/fire drill: Feb 20, 2025
Plan of Correction due date: Apr 17, 2025
Plan of Correction certificate submission date: Apr 25, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Scott Davis | Executive Director | Met with during inspection and received report and plan of corrections |
| Anthony Loera | Licensing Program Analyst | Conducted inspection and authored report |
| Kimberley Mota | Licensing Program Manager | Named in report as licensing program manager |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 118
Deficiencies: 0
Date: Dec 5, 2024
Visit Reason
Unannounced visit/investigation of a complaint alleging inadequate food service and staff eating residents' food.
Complaint Details
Complaint was unsubstantiated due to lack of preponderance of evidence despite multiple unannounced visits and inspections.
Findings
The investigation found the kitchen well stocked with a variety of food meeting or exceeding regulatory requirements. Although allegations may be true or valid, there was insufficient evidence to prove or disprove them, resulting in an unsubstantiated finding.
Report Facts
Capacity: 118
Census: 86
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
Inspection Report
Follow-Up
Census: 74
Capacity: 118
Deficiencies: 1
Date: Nov 14, 2024
Visit Reason
The visit was an unannounced Case Management - Incident Visit to follow up on a self-reported incident involving a resident elopement.
Findings
The facility failed to provide adequate supervision to resident R1, resulting in an elopement. The resident was found outside the community at a neighborhood park without injuries. A deficiency was cited for this failure.
Deficiencies (1)
Facility failed to provide supervision to R1 resulting in an elopement, posing an immediate risk to resident health, safety, and rights.
Report Facts
Civil Penalty: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimari Pinkney | Administrator | Met during inspection and involved in exit interview. |
| Scott Davis | Executive Director | Met during inspection. |
| Anthony Loera | Licensing Program Analyst | Conducted the inspection and signed the report. |
| Kimberley Mota | Licensing Program Manager / Supervisor | Named as supervisor and licensing program manager. |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 118
Deficiencies: 1
Date: Aug 29, 2024
Visit Reason
The visit was an unannounced case management inspection to amend a prior complaint report from 06/20/2024 and to issue a deficiency stemming from the investigation of a complaint received on 04/15/2024 regarding abuse of residents by a staff person.
Complaint Details
The complaint investigation was substantiated by findings that facility staff did not report suspected abuse within 24 hours as required by law, based on a complaint received on 04/15/2024 and abuse occurring prior to 04/12/2024.
Findings
The investigation revealed that facility staff failed to make timely telephone and written reports of suspected physical abuse of residents by a staff person within the required 24-hour timeframe, posing an immediate risk to resident health and safety.
Deficiencies (1)
Failure to complete telephone and written reports of suspected physical abuse within required time frames as mandated by law.
Report Facts
Census: 76
Total Capacity: 118
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Program Analyst | Conducted the inspection and authored the report |
| Carla Martinez | Licensing Program Manager | Supervisor overseeing the inspection |
| Scott Davis | Facility representative met during inspection | |
| Ric Pielstick | Administrator/Director | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 118
Deficiencies: 0
Date: Jul 23, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that facility staff did not provide adequate food service, food of good quality, and were not adequately meeting residents' needs.
Complaint Details
Complaint control number 21-AS-20240611090420 involved allegations regarding inadequate food service and quality. The complaint was investigated through interviews, observations, and document review, resulting in an unsubstantiated finding.
Findings
After interviews, observations, and document reviews, the investigation found that while the allegations may be valid, there was not a preponderance of evidence to prove the violations occurred. Food quality was found to have improved with the onboarding of a new chef, and food was stored according to regulations. The allegations were determined to be unsubstantiated.
Report Facts
Capacity: 118
Census: 77
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Helena Rummonds | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Victoria Bertozzi | Licensing Program Manager | Named in the report as Licensing Program Manager |
| Nathan Howland | Memory Care Director | Met with during the investigation |
| Ric Pielstick | Administrator | Facility administrator named in the report |
Inspection Report
Census: 78
Capacity: 118
Deficiencies: 0
Date: Jun 20, 2024
Visit Reason
The inspection was an unannounced non-compliance inspection conducted as a case management visit to follow up on previously addressed areas from a non-compliance meeting dated 07/21/2021.
Findings
The facility had residents with unlocked medications not allowed per physician's reports, but no residents were retained with prohibited conditions. The facility was found to have adequate medical assessments and timely medical attention. Staffing in memory care was inadequate, and food storage was in the process of reorganization. Reporting requirements were met, and no deficiencies were cited during the inspection.
Report Facts
Resident files reviewed: 10
Staff training hours: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ric Pielstick | Executive Director | Met with Licensing Program Analyst during inspection |
| Helena Rummonds | Licensing Program Analyst | Conducted the non-compliance inspection |
| Victoria Bertozzi | Licensing Program Manager | Named in report header and signature section |
Inspection Report
Annual Inspection
Census: 78
Capacity: 118
Deficiencies: 1
Date: Jun 20, 2024
Visit Reason
The inspection was an unannounced annual required inspection conducted by Licensing Program Analysts to evaluate compliance with regulations at the facility.
Findings
The facility was generally compliant with regulations including environmental safety, food storage, and staff training; however, a deficiency was noted in the Memory Care unit where resident bed sheets were wet and had an incontinence odor, posing a potential health and safety risk.
Deficiencies (1)
Residents' bed sheets were wet and had an incontinence odor throughout the Memory Care unit, violating requirements to keep incontinent residents clean and dry and the facility free of odors.
Report Facts
Capacity: 118
Census: 78
POC Due Date: Jul 5, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ric Pielstick | Administrator | Met with during inspection and named in report |
| Kimberley Mota | Licensing Program Manager | Supervisor named in deficiency report |
| Jacqueline Macias | Licensing Program Analyst | Evaluator and signature on report |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 118
Deficiencies: 1
Date: Jun 20, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff abused a resident in care.
Complaint Details
The complaint alleged staff abused a resident in care. The allegation was substantiated. Staff member S1 physically abused multiple residents over a two-week period. S1 was arrested and excluded from the facility. Facility staff failed to fulfill mandated reporting requirements.
Findings
The allegation of staff abuse was substantiated based on interviews, document review, and record review. Staff member S1 was found to have physically abused multiple residents, and the facility failed to fulfill mandated reporting requirements.
Deficiencies (1)
Licensee did not comply with the requirement to protect residents from physical abuse by staff member S1, violating personal rights under CCR 87468.2(a)(8).
Report Facts
Capacity: 118
Census: 78
Plan of Correction Due Date: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ric Pielstick | Executive Director | Met with Licensing Program Analysts during the investigation |
| Helena Rummonds | Licensing Program Analyst | Conducted the complaint investigation |
| Jacky Macias | Licensing Program Analyst | Arrived unannounced to deliver findings regarding the complaint |
| Carla Martinez | Licensing Program Manager | Named in report as Licensing Program Manager |
| David Leibert | Licensing Program Analyst | Named in report as Licensing Program Analyst |
| Victoria Bertozzi | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 75
Capacity: 118
Deficiencies: 0
Date: Mar 28, 2024
Visit Reason
The inspection was an unannounced case management visit focused on legal and non-compliance issues, following up on areas addressed during a prior non-compliance meeting dated 07/21/2021.
Findings
The facility was found to have no unlocked medications in resident apartments, no residents retained with prohibited conditions, and medical assessments were complete. However, the facility failed to provide pre-admission appraisals for one resident file, had inadequate direct care staffing in memory care, and failed to report certain incidents within the required seven-day timeframe. No deficiencies were cited during the inspection.
Report Facts
Incident reports received late: 4
Resident files reviewed: 6
Caregivers on shift: 4
Medication Technicians on shift: 2
Night shift staff: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ric Pielstick | Executive Director | Met with Licensing Program Analyst during inspection |
| Helena Rummonds | Licensing Program Analyst | Conducted the inspection and authored the report |
| Victoria Bertozzi | Licensing Program Manager | Named in report header and signature section |
Inspection Report
Complaint Investigation
Census: 118
Capacity: 118
Deficiencies: 1
Date: Mar 28, 2024
Visit Reason
Unannounced complaint investigation visit conducted due to allegations that staff did not provide resident's responsible party with proper rate increase notice and were not following terms of the admission agreement.
Complaint Details
Complaint was substantiated. Allegations included failure to provide proper rate increase notice and not following terms of admission agreement. Facility was unable to prove timely notification to resident's responsible party prior to 12/8/2023.
Findings
The investigation substantiated that the facility did not provide proper rate increase notice within two business days to the resident's responsible party as required by regulation. Documentation showed discrepancies in rent charges and failure to prove timely communication of cost of care increases.
Deficiencies (1)
Facility did not ensure a proper rate increase notice was provided within two business days to resident and/or their responsible party as required by regulation.
Report Facts
Capacity: 118
Census: 118
Billable points: 25
Monthly rent agreed: 3095
Cost of care monthly: 855
Total monthly payment: 3950
Billable points reassessment: 126
Cost of care monthly reassessment: 2520
Overcharge amount: 435
Plan of Correction due date: Apr 9, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Helena Rummonds | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Victoria Bertozzi | Licensing Program Manager | Oversaw the complaint investigation |
| Ric Pielstick | Executive Director | Facility representative met during investigation |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 118
Deficiencies: 1
Date: Jan 11, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations that staff did not administer resident's medications as prescribed and did not ensure the resident's medication was filled.
Complaint Details
The complaint involved allegations that staff failed to administer medications as prescribed and failed to ensure medication was filled. The missed medication administration was due to a refill delay by the Medical Clinic and was unsubstantiated. The failure to timely notify the resident's authorized representative about the medication issue was substantiated.
Findings
The investigation found that the facility ran out of a medication for Resident 1 resulting in missed administration on 10/29/2023 and 10/30/2023 due to a delay in medication refill by the Medical Clinic. The facility made reasonable attempts to obtain the medication. The allegations regarding missed medication administration were unsubstantiated. However, the allegation that staff did not communicate with the resident's authorized representative was substantiated, as the representative was not notified timely about the medication issue, violating the resident's personal rights.
Deficiencies (1)
R1’s Representative not notified of medication issue timely, posing an immediate violation of R1’s personal rights.
Report Facts
Capacity: 118
Census: 74
Deficiency count: 1
Plan of Correction Due Date: Jan 15, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Liza Hix | Administrator | Facility administrator met during investigation |
| Carla Martinez | Licensing Program Manager | Named in report as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 118
Deficiencies: 1
Date: Dec 27, 2023
Visit Reason
The inspection was conducted as a Case Management on an Incident Report received by Community Care Licensing regarding a resident found wandering outside the facility grounds.
Complaint Details
The visit was complaint-related based on an incident report of a resident found wandering outside the facility. The complaint was substantiated by the finding that staff did not respond to the auditory exit alert device.
Findings
The facility failed to respond to the auditory exit alert device, allowing a resident with dementia and exit-seeking behavior to elope. The facility has since retrained staff, placed a wanderguard alert device on the resident, increased supervision, and assigned a 1:1 companion.
Deficiencies (1)
The licensee did not comply with the requirement to have an auditory device or other staff alert feature to monitor exits, as staff did not respond to the auditory device on the exit door in the Memory Care Unit, allowing a resident to elope.
Report Facts
Capacity: 118
Census: 84
Deficiencies cited: 1
Plan of Correction Due Date: Dec 28, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Liza Hix | Executive Director | Met during inspection and involved in discussion of incident |
| Kimari Pinkney | Health Service Director | Met during inspection and involved in discussion of incident |
| Helena Rummonds | Licensing Program Analyst | Conducted inspection and signed report |
| Victoria Bertozzi | Licensing Program Manager | Conducted inspection |
| Bethany Moellers | Supervisor | Named as supervisor and Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 118
Deficiencies: 0
Date: Dec 27, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to allegations including failure to seek timely medical care resulting in resident death, staff not meeting residents' care needs, and staff stealing residents' medication.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included delayed medical response leading to resident death, staff stealing medications, and inadequate care and training. Evidence did not support these claims.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Interviews, document reviews, and observations did not support claims of delayed medical care, medication theft, or inadequate staff training. No deficiencies were cited during the inspection.
Report Facts
Capacity: 118
Census: 84
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Liza Hix | Executive Director | Met with investigators during complaint investigation |
| Kimari Pinkney | Health Service Director | Met with investigators during complaint investigation |
| Helena Rummonds | Licensing Program Analyst | Conducted complaint investigation |
| Victoria Bertozzi | Licensing Program Manager | Conducted complaint investigation |
| Bethany Moellers | Licensing Program Manager | Named in report signature |
Inspection Report
Census: 74
Capacity: 118
Deficiencies: 0
Date: Nov 9, 2023
Visit Reason
The visit was an unannounced Case Management on Incident Reports received by Community Care Licensing on 11/03/2023 and 11/08/2023.
Findings
Two incidents were reviewed: one involving a resident found injured after an alleged bump by another resident, and another involving a missing watch and cash reported by a resident. No deficiencies were cited during the visit.
Report Facts
Value of missing watch: 200
Value of missing cash: 50
Confidential names provided: 811
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Liza Hix | Executive Director | Met with Licensing Program Analyst during visit and discussed incidents |
| Tristan Amari | Business Office Director | Reviewed and signed report due to Executive Director's schedule conflict |
| Helena Rummonds | Licensing Program Analyst | Conducted the unannounced case management visit |
| Bethany Moellers | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 118
Deficiencies: 7
Date: Oct 13, 2023
Visit Reason
Unannounced case management Legal/Non-compliance inspection conducted to follow up on items concerning a prior Non-Compliance Conference dated 7/2/21 and to investigate deficiencies discovered during a complaint investigation.
Complaint Details
The inspection was triggered by a complaint investigation (#21-AS-20230901102047). Incident reports revealed delays in reporting incidents to the licensing agency, including an incident on 9/20/23 reported on 10/4/23, which was not within the required 7 days.
Findings
The facility had multiple deficiencies including unlocked medications without physician crush orders, retention of a resident with a prohibited condition, incomplete medical assessments, failure to seek timely medical attention, inadequate staffing in memory care, failure to report incidents timely, and staff training deficiencies.
Deficiencies (7)
Residents had unlocked medications without physician crush orders for some residents.
Facility retained a resident with a prohibited condition and failed to maintain current resident care notes.
Facility failed to ensure residents' medical assessments/physician's reports were complete and updated within 12 months.
Facility failed to seek timely medical attention as required.
Facility memory care did not have adequate direct care staff to support residents' needs.
Facility failed to report incidents such as refusal of medications, 911 calls, and suspected abuse within required timeframes.
Two out of six staff did not complete required 20 hours annual training including medication training.
Report Facts
Capacity: 118
Census: 91
Staff training deficiency count: 2
Incident reporting delay: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Liza Hix | Executive Director/acting Administrator | Met with Licensing Program Analysts during inspection and involved in discussion of findings. |
| Marisol Cuadra | Licensing Program Analyst | Conducted inspection and authored report. |
| Bethany Moellers | Licensing Program Manager | Supervised inspection and signed report. |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 118
Deficiencies: 0
Date: Oct 13, 2023
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 2023-09-01 alleging that staff violated residents' personal rights.
Complaint Details
The complaint alleged that staff member S1 held up two fists as if to punch resident R1 and intimidated them. Police service call records showed a possible assault with a final disposition of Unfounded. Incident reports were not submitted to the licensing agency as required. The allegation was unsubstantiated.
Findings
The investigation found contradictory information and no supporting evidence that staff violated residents' personal rights. The complaint allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 118
Census: 91
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marisol Cuadra | Licensing Program Analyst | Conducted the complaint investigation |
| Bethany Moellers | Licensing Program Manager | Named in report as Licensing Program Manager |
| Liza Hix | Executive Director | Met with Licensing Program Analysts during investigation |
| Ric Pielstick | Administrator | Facility Administrator named in report |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 118
Deficiencies: 0
Date: Aug 17, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to allegations received on 05/24/2023 regarding failure to seek medical attention and neglect/lack of supervision at Oakmont of Novato facility.
Complaint Details
The complaint investigation was triggered by allegations of failure to seek medical attention and neglect/lack of supervision related to resident R1. The investigation concluded both allegations were unsubstantiated due to insufficient evidence to prove violations occurred.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. The complaint of failure to seek medical attention was unsubstantiated as the facility had active communication with responsible parties and appropriate medical care was documented. The allegation of neglect/lack of supervision was also unsubstantiated based on staff schedules, training records, and interviews.
Report Facts
Capacity: 118
Census: 94
Staff count: 4
Med tech count: 1
Training records reviewed: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marisol Cuadra | Licensing Program Analyst | Conducted complaint investigation |
| Bethany Moellers | Licensing Program Manager | Oversaw complaint investigation |
| Tristan Amari | Business Office Director | Met with investigators during complaint investigation |
Inspection Report
Capacity: 118
Deficiencies: 4
Date: Jul 6, 2023
Visit Reason
The purpose of this office meeting was to discuss the Non-Compliance plan (NCC) from Oakmont of Novato facility, which was extended due to unresolved operational concerns. The meeting reviewed progress on the NCC and discussed additional civil penalties under review.
Complaint Details
Ten complaints have been received since the licensure date of 06/09/2022. The Non-Compliance Plan was originally implemented on 07/22/2021 based on substantiated findings from complaint investigations.
Findings
The facility had multiple areas of non-compliance including failure to seek timely medical attention, inadequate staffing in the memory care unit, improper handling and securing of medications resulting in errors, and incomplete resident medical assessments and care notes.
Deficiencies (4)
Facility failed to seek timely medical attention.
Facility memory care unit didn't have adequate number of direct care staff to support each resident's physical, social, emotional, safety and health care needs.
Facility did not ensure that resident’s medications were properly handled, secured per resident’s physician reports resulting in medication errors.
Facility did not ensure that resident’s medical assessments and updated resident's care notes were available for review.
Report Facts
Capacity: 118
Complaints: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ric Pielstick | Executive Director | Met during the office meeting and named in report |
| Bethany Moellers | Licensing Program Manager | Present during meeting and named in report |
| Marisol Cuadra | Licensing Program Analyst | Present during meeting and named in report |
Inspection Report
Annual Inspection
Census: 79
Capacity: 118
Deficiencies: 3
Date: Jun 29, 2023
Visit Reason
The inspection was an unannounced annual required inspection and case management Legal/Non-compliance visit to evaluate compliance with regulations and follow up on previous concerns.
Complaint Details
The visit included follow-up on three incident reports of suspected financial abuse involving missing money and jewelry from residents' apartments. The facility is conducting an internal investigation with findings due by 06/30/2023. Police were notified and cases are open.
Findings
The facility was generally compliant with environmental and safety regulations, but deficiencies were noted including unsanitary conditions in a bathroom, unlocked medications previously, incomplete resident care notes, inadequate staffing in memory care, incomplete medical assessments for one resident, and failure to obtain criminal record clearance for one staff member. The facility is conducting an internal investigation regarding suspected financial abuse incidents.
Deficiencies (3)
Bathroom located at room #124 needed assistance; toilet and bathroom floor had feces on it, posing an immediate health, safety or personal rights risk.
Facility did not ensure criminal record clearance for staff (S9) prior to working, residing or providing care, posing immediate health, safety and personal rights risk. Civil penalty assessed.
One out of ten resident medical assessments was not updated within the last 12 months as required, posing potential health, safety or personal rights risk.
Report Facts
Residents under hospice: 4
Residents in Assisted Living: 48
Residents in Memory Care: 31
Staff in Memory Care: 4
Med Tech in Memory Care: 1
Civil penalty amount: 100
Missing money reported: 260
Incident dates: 3
Resident files reviewed: 10
Staff files reviewed: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ric Pielstick | Administrator | Met during inspection and named in findings related to facility operations and compliance |
| Marisol Cuadra | Licensing Program Analyst | Conducted the inspection and authored the report |
| Bethany Moellers | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 79
Capacity: 118
Deficiencies: 2
Date: Jun 1, 2023
Visit Reason
The inspection visit was conducted unannounced to deliver findings on a complaint investigation regarding missing personal property of a former resident.
Complaint Details
The visit was triggered by a complaint investigation concerning missing personal property of former resident R1. The complaint was substantiated by findings that the facility did not produce required documentation and did not follow loss procedures.
Findings
The facility failed to produce an inventory or waiver for the personal property of former resident R1 and did not follow the facility's Theft and Loss policies when glasses and hearing aids belonging to R1 were found missing.
Deficiencies (2)
Failure to complete the initial personal property inventory for resident R1, posing a potential risk to personal rights.
Failure to follow the facility's Loss policies in response to missing glasses and hearing aids of resident R1, posing a potential risk to personal rights.
Report Facts
Capacity: 118
Census: 79
Plan of Correction Due Date: Jun 15, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Carla Martinez | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 79
Capacity: 118
Deficiencies: 1
Date: Jun 1, 2023
Visit Reason
Unannounced complaint investigation visit conducted in response to multiple allegations including failure to safeguard resident's personal belongings, failure to meet incontinence needs, improper supervision, failure to assist with showering, and failure to refund responsible party after resident moved out.
Complaint Details
Complaint investigation was unannounced and conducted by Evaluator David Leibert. Allegations included failure to safeguard resident's personal belongings, failure to meet incontinence needs, improper supervision, failure to assist with showering, and failure to refund responsible party after resident moved out. The refund allegation was substantiated; others were unsubstantiated.
Findings
The investigation found the allegations regarding personal belongings and care needs to be unsubstantiated due to insufficient evidence. However, the allegation that the facility failed to refund the responsible party within the required timeframe was substantiated, resulting in a cited deficiency.
Deficiencies (1)
Failure to refund fees paid in advance within 15 days after resident's personal property was removed from the facility as required by Health and Safety Code 1569.652(c).
Report Facts
Capacity: 118
Census: 79
Deficiency count: 1
Plan of Correction Due Date: Jun 8, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Ric Pielstick | Administrator | Facility administrator mentioned in report |
| Liza Hix | Met with Licensing Program Analyst during investigation | |
| Carla Martinez | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 118
Deficiencies: 0
Date: May 16, 2023
Visit Reason
The inspection was conducted as a case management visit regarding a recently self-reported incident involving suspected physical abuse between two residents.
Complaint Details
The visit was triggered by a complaint related to a suspected physical abuse incident reported on 5/11/2023 involving residents R1 and R2. The complaint was investigated, and law enforcement found no evidence to proceed. The facility agreed to discard a 3-day eviction notice to R1 and instead issue a 30-day notice while arranging relocation.
Findings
The investigation found that the incident involved resident R1 allegedly causing harm to resident R2, with prior similar incidents noted. The facility took steps including notifying responsible parties, offering room changes, and providing one-on-one staff support. Law enforcement was involved but found insufficient evidence to proceed. No deficiencies were cited during this inspection.
Report Facts
Incident date: May 6, 2021
Eviction notice days: 3
Eviction notice days: 30
One-on-one staff hours: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ric Pielstick | Administrator | Met with Licensing Program Analyst during inspection and involved in case management |
| Marisol Cuadra | Licensing Program Analyst | Conducted the case management inspection |
| Bethany Moellers | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Census: 82
Capacity: 118
Deficiencies: 0
Date: Apr 28, 2023
Visit Reason
Licensing Program Analyst Leibert arrived unannounced to amend a case management and citation report that was issued on 2023-04-06 by LPA Cuadra.
Findings
The report was amended and a copy was left at the facility.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ric Pielstick | Administrator | Met with during the visit. |
| David Leibert | Licensing Program Analyst | Conducted the unannounced visit to amend the report. |
| Carla Martinez | Licensing Program Manager | Named in the report header. |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 118
Deficiencies: 0
Date: Apr 28, 2023
Visit Reason
Unannounced visit/investigation of a complaint received on 2023-02-03 regarding multiple resident falls due to lack of supervision and failure to dispense medication as prescribed.
Complaint Details
Complaint was unsubstantiated due to lack of sufficient evidence to prove or disprove the allegations regarding resident falls and medication administration.
Findings
The investigation found insufficient evidence to substantiate the allegations of falls due to lack of supervision and medication not being dispensed as prescribed. A medication for one resident was not administered on two specific dates, but delays were due to medication availability. Fall management programs were in place and staff responses were appropriate.
Report Facts
Complaint Control Number: 21
Medication non-administration dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Evaluator / Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Ric Pielstick | Administrator | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 118
Deficiencies: 1
Date: Apr 6, 2023
Visit Reason
Unannounced case management Legal/Non-compliance inspection conducted to follow up on concerning items and ensure compliance with a Non-Compliance Conference dated 7/2/21, including medication administration errors and resident care issues.
Complaint Details
The visit was complaint-related following a self-report of a medication error on 3/4/2023 and a suspected physical abuse incident on 3/31/2023. The physical abuse incident was investigated and determined to be not substantiated, but further investigation is needed. The medication error resulted in staff retraining.
Findings
The facility had residents with unlocked medications contrary to physician orders, a medication error occurred on 3/4/2023 resulting in staff retraining, retention of a resident with a prohibited condition, failure to seek timely medical attention, incomplete medical assessments, inadequate staffing in memory care, and failure to report certain incidents. An incident of suspected physical abuse on 3/31/2023 was investigated and found not substantiated but requires further review.
Deficiencies (1)
Facility failed to administer medication per physician’s orders, posing an immediate health and safety risk to clients in care.
Report Facts
Census: 82
Total Capacity: 118
Staffing: 4
Staffing: 1
Resident Medical Records Reviewed: 6
Residents Assessed for Change of Condition: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ric Pielstick | Executive Director/Administrator | Met with Licensing Program Analyst during inspection |
| David Leibert | Licensing Program Analyst | Conducted inspection and authored report |
| Marisol Cuadra | Licensing Program Analyst | Conducted inspection and authored report |
| Carla Martinez | Licensing Program Manager | Supervised inspection |
Inspection Report
Census: 82
Capacity: 118
Deficiencies: 0
Date: Apr 3, 2023
Visit Reason
The inspection was an unannounced case management visit conducted by the Licensing Program Analyst to evaluate the facility.
Findings
The facility was found to be clean and comfortable with residents engaged in activities. No deficiencies or citations were identified during the inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ric Pielstick | Administrator | Met with Licensing Program Analyst during inspection |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 118
Deficiencies: 0
Date: Mar 21, 2023
Visit Reason
Unannounced visit/investigation of a complaint received on 2022-11-01 regarding allegations that facility staff do not prevent altercations between residents and do not report incidents to licensing.
Complaint Details
Complaint was unsubstantiated. Allegations included failure to prevent resident altercations and failure to report incidents to licensing. No citations were issued.
Findings
The investigation found that residents involved displayed aggressive behaviors addressed in care plans, with reasonable steps taken by staff and most incidents reported as required. Two incidents were not reported but may not have required reporting. The allegations were unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 118
Census: 82
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Ric Pielstick | Administrator | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 118
Deficiencies: 1
Date: Mar 21, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by complaints received on 11/16/2022 regarding resident care and supervision issues at Oakmont of Novato.
Complaint Details
The complaint investigation was unannounced and addressed allegations including resident injury due to lack of care and supervision, failure to report incidents to authorized persons, and staff not meeting resident needs. One allegation was substantiated based on evidence of neglect and poor hygiene, while others were unsubstantiated due to insufficient evidence.
Findings
The investigation found one allegation unsubstantiated regarding injury due to lack of care and supervision, and one allegation substantiated regarding staff not meeting resident's needs, including neglect evidenced by poor hygiene and a broken wheelchair. The substantiated deficiency posed an immediate risk to resident health and safety.
Deficiencies (1)
Based on statements and observations, R1 was observed in need of hygiene services, in a broken wheelchair and, on one occasion, with feces under the fingernails, posing an immediate risk to health and safety.
Report Facts
Capacity: 118
Census: 78
Plan of Correction Due Date: Mar 27, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Ric Pielstick | Administrator | Facility administrator met with Licensing Program Analyst during investigation |
| Carla Martinez | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Census: 82
Capacity: 118
Deficiencies: 0
Date: Mar 1, 2023
Visit Reason
The case management inspection was conducted to follow up on three self-reported incidents involving resident behaviors and medication administration.
Findings
The inspection found that resident aggressive behaviors were managed with staff intervention and increased supervision, and a medication incident was documented as not unintentional. No deficiencies were cited during the inspection.
Report Facts
Incident reports: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ric Pielstick | Administrator | Met during inspection and involved in case management discussion |
| Tristan Amari | Business Office Director | Met during inspection |
| Jill Nakagawa | Licensing Program Analyst | Conducted the case management inspection |
| Kimberley Mota | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 118
Deficiencies: 1
Date: Mar 1, 2023
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to a complaint received on 2023-02-23 regarding staff not preventing a resident's television from interfering with another resident's sleep.
Complaint Details
The complaint was substantiated. Staff did not prevent the television volume from interfering with a resident's sleep, violating personal rights. The preponderance of evidence standard was met.
Findings
The investigation found that staff failed to ensure the television volume was controlled, resulting in interference with a resident's sleep. The allegation was substantiated based on record review, observations, and interviews.
Deficiencies (1)
Failure to ensure residents' personal rights by allowing occasional loud television volume interfering with another resident's sleep, violating CCR 87468.1(a)(3).
Report Facts
Capacity: 118
Census: 82
Plan of Correction Due Date: Mar 7, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ric Pielstick | Administrator | Met during investigation and named in findings |
| Jill Nakagawa | Licensing Program Analyst | Conducted the complaint investigation |
| Marisol Cuadra | Licensing Program Analyst | Conducted investigation and signed report |
Inspection Report
Follow-Up
Census: 78
Capacity: 118
Deficiencies: 0
Date: Jan 24, 2023
Visit Reason
Licensing Program Analyst Leibert arrived unannounced to follow up on the Plan of Correction (POC) for citations issued on January 12, 2023, related to a complaint and case management issues.
Complaint Details
The visit was a follow-up on citations issued due to a complaint and case management issues. Deficiencies are expected to be cleared based on submitted documentation.
Findings
The analyst obtained documentation for required staff training and will clear the deficiencies. No citations were issued during this visit. Additionally, a prior report was amended to include the Administrator's name.
Report Facts
Capacity: 118
Census: 78
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ric Pielstick | Administrator | Facility Administrator met during the inspection |
| David Leibert | Licensing Program Analyst | Conducted the follow-up inspection and obtained documentation |
| Carla Martinez | Licensing Program Manager | Named in the report header |
Inspection Report
Census: 79
Capacity: 118
Deficiencies: 1
Date: Jan 19, 2023
Visit Reason
The inspection was an unannounced Case Management Legal/Non-Compliance visit conducted to follow up on a previously submitted incident report involving a medication error.
Findings
The memory care unit was found clean, orderly, and adequately staffed. A medication error was identified from a prior incident report where a staff member failed to ensure the correct medication dosage was administered, posing an immediate health and safety risk.
Deficiencies (1)
Based on incident report of 11/26/22 and interview with medical staff, staff member (S1) failed to ensure that resident received the right dosage of medication as prescribed by physician which poses an immediate health and safety risk to clients in care.
Report Facts
Resident files reviewed: 8
Care staff in Traditions: 4
Other staff in Traditions: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ric Pielstick | Administrator | Met with Licensing Program Analyst during inspection |
| Jill Nakagawa | Licensing Program Analyst | Conducted the inspection and authored the report |
| Kimberley Mota | Licensing Program Manager | Supervisor of the inspection |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 118
Deficiencies: 1
Date: Jan 12, 2023
Visit Reason
The inspection was conducted as a complaint investigation following a report regarding unsecured hazardous items in the facility.
Complaint Details
During the complaint investigation, the Licensing Program Analyst observed the unsecured bottle of fingernail polish remover in the Memory Care bathroom. The item was removed and the Memory Care Director committed to providing additional refresher training for staff.
Findings
A bottle of fingernail polish remover was found unsecured and accessible in the Memory Care bathroom, posing an immediate risk to residents. The facility was cited for this deficiency and a plan of correction was required.
Deficiencies (1)
Storage Space. 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. Finger nail polish remover was observed unsecured in the Memory Care apartment bathroom accessible to residents, posing an immediate risk to their health.
Report Facts
Plan of Correction Due Date: Jan 18, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Program Analyst | Observed the deficiency and signed the report |
| Carla Martinez | Licensing Program Manager | Supervisor named in the report |
| Ric Pielstick | Administrator | Facility administrator met during the visit |
Inspection Report
Complaint Investigation
Capacity: 118
Deficiencies: 1
Date: Jan 12, 2023
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that the facility vaccinated a resident without obtaining permission from the resident's responsible party.
Complaint Details
The complaint was substantiated based on evidence that the resident's responsible person did not consent to the vaccination given at the facility flu shot clinic on October 27, 2022.
Findings
The investigation substantiated the allegation that the facility provided a flu shot to a resident during a facility-sponsored clinic without the consent of the resident's responsible person, posing an immediate risk to the resident's health and personal rights.
Deficiencies (1)
Facility sponsored flu shot clinic where resident obtained vaccine without personal representative's knowledge or consent, violating personal rights of residents.
Report Facts
Capacity: 118
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Ric Pielstick | Administrator | Facility administrator met with investigator during the complaint investigation |
| Carla Martinez | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 118
Deficiencies: 1
Date: Dec 22, 2022
Visit Reason
Unannounced complaint investigation visit conducted due to allegations that a resident sustained multiple injuries due to a fall during a transfer.
Complaint Details
Complaint investigation was conducted for allegations including resident sustaining multiple injuries due to a fall during transfer, failure of administrator to report unusual incident, mold issues, and uncleared adults providing care. Only the injury allegation was substantiated; others were unsubstantiated due to lack of preponderance of evidence.
Findings
The allegation that a resident sustained multiple injuries due to a fall during a transfer was substantiated based on observations and record reviews. Other allegations regarding failure to report an unusual incident, mold issues, and uncleared adults providing care were found to be unsubstantiated. One deficiency was cited related to personnel requirements due to a caregiver transferring a resident alone instead of with two-person assist as required by the care plan.
Deficiencies (1)
Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Staff transferred resident by themselves rather than by 2-person assist as required in care plan, posing immediate risk to resident health and safety.
Report Facts
Capacity: 118
Census: 91
Deficiency Type: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ric Pielstick | Administrator | Named in relation to allegation of failure to report unusual incident |
| Tristan Amir | Business Office Manager | Met with Licensing Program Analysts during investigation |
| Jill Nakagawa | Licensing Program Analyst | Conducted complaint investigation and signed report |
| Kimberley Mota | Licensing Program Manager | Named as Licensing Program Manager overseeing investigation |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 118
Deficiencies: 1
Date: Dec 22, 2022
Visit Reason
The visit was conducted to address deficiencies noted during a complaint investigation related to staff fingerprinting and association with the facility.
Complaint Details
The visit was complaint-related, with deficiencies substantiated by findings of fingerprinting and staff association violations.
Findings
The investigation found one staff member not fingerprinted and three staff cleared but not associated with the facility, resulting in immediate civil penalties of $400.
Deficiencies (1)
One staff member not fingerprinted and three staff not associated with the facility, posing an immediate risk to health, safety, and personal rights of residents.
Report Facts
Immediate Civil Penalties: 400
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tristan Amari | Business Office Director | Met with Licensing Program Analysts to address deficiencies. |
| Ric Pielstick | Executive Director | Available by phone during the investigation. |
| Kimberley Mota | Licensing Program Manager | Named as supervisor and licensing program manager. |
| Jill Nakagawa | Licensing Program Analyst | Conducted the investigation and signed the report. |
Inspection Report
Complaint Investigation
Census: 83
Capacity: 118
Deficiencies: 0
Date: Nov 15, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility did not provide a resident's records to the responsible party.
Complaint Details
The complaint alleged that the facility did not provide resident's records to the responsible party. The allegation was unsubstantiated as records were released to the responsible party on 11/3/2022 after verification.
Findings
The investigation found that the facility did provide the resident's records to the responsible party after confirming the validity of the legal services firm representing the resident. The complaint allegation was determined to be unsubstantiated.
Report Facts
Capacity: 118
Census: 83
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ric Pielstick | Executive Director | Met with Licensing Program Analyst during the investigation and named in the report |
| Marisol Cuadra | Licensing Program Analyst | Conducted the complaint investigation |
| Bethany Moellers | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Census: 91
Capacity: 118
Deficiencies: 1
Date: Oct 20, 2022
Visit Reason
An unannounced random required non-compliance inspection was conducted as part of case management for legal/non-compliance reasons.
Findings
The facility was found to be clean and in good repair with proper food storage and staffing. However, 4 out of 6 resident medical assessments were incomplete, specifically residents R1-R4 had not submitted signed physician reports, posing a potential health and safety risk.
Deficiencies (1)
Failure to ensure Residents (R1-4) had submitted a completed medical assessment signed by a physician within the last year.
Report Facts
Residents with incomplete medical assessments: 4
Resident records reviewed: 6
Facility census: 91
Facility capacity: 118
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ric Pielstick | Executive Director | Met with Licensing Program Analyst during inspection. |
| Jill Nakagawa | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Kimberley Mota | Licensing Program Manager | Supervisor named in the report. |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 118
Deficiencies: 1
Date: Sep 29, 2022
Visit Reason
The visit was an unannounced case management inspection conducted to close a complaint investigation and to assess related deficiencies observed during the visit.
Complaint Details
The visit was conducted to close a complaint investigation. The complaint was substantiated by findings that the facility did not report incidents involving residents R1 and R2 in a timely manner.
Findings
The investigation found that the facility failed to timely report two incidents involving residents: a fall resulting in an ER visit on 7/22/2022 and a medication refusal on 8/3/2022. These incidents were not reported to the Department as required.
Deficiencies (1)
Failure to comply with reporting requirements for two residents' incidents, posing a potential risk to their health, safety, and personal rights.
Report Facts
Deficiencies cited: 1
Plan of Correction Due Date: Oct 13, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ric Pielstick | Executive Director | Met with Licensing Program Analyst during investigation |
| Bethany Moellers | Licensing Program Manager | Supervisor named in report |
| Carla Fernandes-Goes | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 118
Deficiencies: 3
Date: Sep 29, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 07/27/2022 regarding allegations that the facility was not following a resident's care plan, staff did not respond to a resident's alarm, and staff did not dispense medication as prescribed.
Complaint Details
The complaint investigation was substantiated. Allegations included failure to follow resident's care plan, failure to respond to resident's alarm, and failure to dispense medication as prescribed. The investigation found sufficient evidence to support these allegations based on observations, interviews, and documentation review.
Findings
The investigation substantiated that the facility failed to follow the resident's care plan, did not respond to the resident's alarm, and did not dispense medication as prescribed. Specific deficiencies included failure to assist with breathing treatments as ordered, failure to respond to sensor alarms leading to a resident wandering and falling, and failure to follow care plan and doctor's orders. Other allegations regarding hygiene assistance, bathroom sanitation, and admission agreement were unsubstantiated. Two Type B deficiencies were cited related to personnel requirements and personal rights, and one deficiency was dismissed.
Deficiencies (3)
Facility did not comply with resident R1 care plan needs, posing a risk to health, safety, and personal rights, including failure to provide breathing treatments and fall management as required.
Facility failed to ensure residents are accorded safe, healthful, and comfortable accommodations; resident R1 had a fall after staff failed to respond to sensor alarms and wandering behavior.
Facility failed to comply with incidental medical and dental care requirements for one resident, including failure to provide breathing treatments due to missing machine parts.
Report Facts
Census: 78
Total Capacity: 118
Deficiency Count: 3
Plan of Correction Due Date: Oct 13, 2022
Missed Treatments: 14
Sensor Alarm Activations: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ric Pielstick | Executive Director | Met with Licensing Program Analyst during investigation and mentioned in findings |
| Carla Fernandes-Goes | Licensing Program Analyst | Conducted the complaint investigation |
| Bethany Moellers | Licensing Program Manager | Named in report as Licensing Program Manager overseeing investigation |
| Juan Ferrel | Memory Care Director | Interviewed regarding housekeeping and care staff duties in memory care |
Inspection Report
Capacity: 118
Deficiencies: 0
Date: Aug 25, 2022
Visit Reason
This meeting was conducted to ensure that the Executive Director is aware and understands the non-compliance plan in place and to review documentation required from the facility under reporting requirements. It also discussed the importance of timely incident reporting.
Complaint Details
The report references substantiated complaint #21-AS-20210310171803 and another Priority 1 complaint under investigation for the facility.
Findings
No deficiencies were cited at this time. The licensee was informed that additional civil penalties are under review due to substantiated complaints and ongoing investigations.
Report Facts
Facility capacity: 118
Census: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ric Pielstick | Executive Director | Met during the inspection and discussed non-compliance plan |
| Bethany Moellers | Licensing Program Manager | Conducted the meeting and signed the report |
| Carla Fernandes-Goes | Licensing Program Analyst | Conducted the meeting and signed the report |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 118
Deficiencies: 1
Date: Aug 3, 2022
Visit Reason
The inspection was a case management visit regarding an incident report submitted for resident R1 who eloped from the facility on 7/30/2022.
Complaint Details
The visit was triggered by a complaint related to an incident where resident R1, diagnosed with dementia, eloped from the assisted living facility without staff knowledge, despite having a wander guard. The complaint was substantiated by the incident report and physician's documentation.
Findings
The facility failed to comply with safety measures to address wandering behaviors for resident R1, who eloped without staff knowledge, posing an immediate health and safety risk. The facility reassessed the resident, conducted staff in-service training, and scheduled an elopement drill.
Deficiencies (1)
Failure to meet safety measures to address behaviors such as wandering for resident R1 who eloped without staff knowledge on 7/30/22.
Report Facts
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ric Pielstick | Executive Director | Met with Licensing Program Analyst during the case management visit |
| Carla Fernandes-Goes | Licensing Program Analyst | Conducted the case management visit and authored the report |
| Bethany Moellers | Licensing Program Manager | Supervisor named in the report |
Inspection Report
Post Licensing
Census: 83
Capacity: 118
Deficiencies: 0
Date: Jul 21, 2022
Visit Reason
The visit was an unannounced Post Licensing Non-Compliance Infection Control inspection conducted to evaluate the facility's compliance with licensing requirements.
Findings
The facility was found to be clean, with proper temperature controls, operational safety equipment, and adequate food and toxin storage. Infection control measures were in place, including PPE availability and staff training. No deficiencies were cited during this inspection.
Report Facts
Residents present: 83
Licensed capacity: 118
Residents under hospice: 3
Hot water temperature range: 107.2-119.3
Resident records reviewed: 6
Resident medications reviewed: 2
Medication supply: 30
Date of last fire extinguisher charge: 202109
Document submission deadline: Jul 28, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ric Pielstick | Executive Director | Met with during inspection and mentioned in report |
| Juan Ferrel | Memory Care Director | Contacted during inspection and participated in facility tour |
| Carla Fernandes-Goes | License Program Analyst | Conducted the inspection and authored the report |
Inspection Report
Capacity: 118
Deficiencies: 0
Date: Jun 14, 2022
Visit Reason
This meeting was conducted to transfer a Compliance Plan Conference which started on July 2, 2021 due to facility new ownership. The visit addressed concerns identified by the Licensing Agency including substantiated complaint investigations and other operational issues.
Complaint Details
The visit included review of substantiated complaints #21-AS-20210310171803 and #21-AS-20210823100922 under formal facility #216803904 Oakmont of Novato. Additional civil penalties are under review by the Department per Health and Safety Code 1569.49 (f).
Findings
No deficiencies were cited at this time. The report noted multiple concerns such as unlocked medications, prohibited resident conditions, failure to seek timely medical attention, incomplete medical assessments, inadequate staffing in memory care, and failure to report incidents. Additional civil penalties are under review due to substantiated complaints.
Report Facts
Facility capacity: 118
Census: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bethany Moellers | Licensing Program Manager | Met with facility representatives during the visit |
| Carla Fernandes-Goes | Licensing Program Analyst | Met with facility representatives during the visit |
| Kathleen Olson | Acting Executive Director | Facility representative met during the visit |
| Sue McPherson | VP of Regulatory | Facility representative met during the visit |
| Mark Maclaine | Vice President of Operations | Facility representative met during the visit |
| Jimmy Duong | Regional Health Service Director Specialist | Facility representative met during the visit |
Inspection Report
Original Licensing
Census: 87
Capacity: 118
Deficiencies: 0
Date: Apr 6, 2022
Visit Reason
The inspection was a pre-licensing visit conducted to evaluate the facility prior to licensure and ensure compliance with regulations.
Findings
The facility was found to be in good repair, with appropriate safety measures, adequate staffing, and proper provisions for residents including special dietary needs and emergency preparedness. No deficiencies were cited at this time, but some items were requested to be corrected prior to licensure.
Report Facts
Residents in memory care: 32
Residents on Hospice: 6
Complaints pending investigation: 6
Complaints closed: 8
Substantiated complaints: 7
Unsubstantiated complaints: 1
Fire clearance capacity: 110
Fire clearance capacity: 8
Fire extinguisher last charged: 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kathleen Olson | Acting Executive Director | Met with Licensing Program Analyst during pre-licensing inspection |
| Carla Fernandes-Goes | Licensing Program Analyst | Conducted the pre-licensing inspection and authored the report |
| Bethany Moellers | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection |
Inspection Report
Capacity: 118
Deficiencies: 0
Date: Mar 1, 2022
Visit Reason
The visit was an office type evaluation related to a change of ownership (CHOW) application for the facility.
Findings
The applicant/administrator successfully completed Component II via telephone call, confirming understanding of Title 22 requirements including facility operation, staff qualifications, program policies, and application document review.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Annemarie Domizio | Administrator | Participant in Component II telephone call confirming understanding of regulatory requirements. |
| Mirella Quaranta | Licensing Program Manager | Named as Licensing Program Manager on the report. |
| Stefania Fonteno | Licensing Program Analyst | Named as Licensing Program Analyst on the report. |
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