Inspection Reports for Oakmont of Montecito

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.

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.

Unannounced visit/investigation of a complaint alleging inadequate food service and staff eating residents' food.

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.

Complaint was unsubstantiated due to lack of preponderance of evidence despite multiple unannounced visits and inspections.

The visit was an unannounced Case Management - Incident Visit to follow up on a self-reported incident involving a resident elopement.

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.

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.

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.

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.

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.

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.

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.

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.

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.

The inspection was an unannounced annual required inspection conducted by Licensing Program Analysts to evaluate compliance with regulations at the facility.

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.

The inspection was an unannounced complaint investigation visit triggered by an allegation that staff abused a resident in care.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

The visit was an unannounced Case Management on Incident Reports received by Community Care Licensing on 11/03/2023 and 11/08/2023.

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.

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.

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.

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.

An unannounced complaint investigation was conducted following a complaint received on 2023-09-01 alleging that staff violated residents' personal rights.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

The inspection visit was conducted unannounced to deliver findings on a complaint investigation regarding missing personal property of a former resident.

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.

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.

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.

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.

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.

The inspection was conducted as a case management visit regarding a recently self-reported incident involving suspected physical abuse between two residents.

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.

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.

Licensing Program Analyst Leibert arrived unannounced to amend a case management and citation report that was issued on 2023-04-06 by LPA Cuadra.

The report was amended and a copy was left at the facility.

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.

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.

Complaint was unsubstantiated due to lack of sufficient evidence to prove or disprove the allegations regarding resident falls and medication administration.

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.

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.

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.

The inspection was an unannounced case management visit conducted by the Licensing Program Analyst to evaluate the facility.

The facility was found to be clean and comfortable with residents engaged in activities. No deficiencies or citations were identified during the inspection.

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.

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.

Complaint was unsubstantiated. Allegations included failure to prevent resident altercations and failure to report incidents to licensing. No citations were issued.

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.

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.

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.

The case management inspection was conducted to follow up on three self-reported incidents involving resident behaviors and medication administration.

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.

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.

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.

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.

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.

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.

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.

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.

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.

The inspection was conducted as a complaint investigation following a report regarding unsecured hazardous items in the facility.

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.

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.

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.

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.

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.

Unannounced complaint investigation visit conducted due to allegations that a resident sustained multiple injuries due to a fall during a transfer.

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.

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.

The visit was conducted to address deficiencies noted during a complaint investigation related to staff fingerprinting and association with the facility.

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.

The visit was complaint-related, with deficiencies substantiated by findings of fingerprinting and staff association violations.

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.

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.

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.

An unannounced random required non-compliance inspection was conducted as part of case management for legal/non-compliance reasons.

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.

The visit was an unannounced case management inspection conducted to close a complaint investigation and to assess related deficiencies observed during the visit.

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.

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.

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.

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.

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.

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.

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.

The report references substantiated complaint #21-AS-20210310171803 and another Priority 1 complaint under investigation for the facility.

The inspection was a case management visit regarding an incident report submitted for resident R1 who eloped from the facility on 7/30/2022.

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.

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.

The visit was an unannounced Post Licensing Non-Compliance Infection Control inspection conducted to evaluate the facility's compliance with licensing requirements.

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.

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.

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.

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).

The inspection was a pre-licensing visit conducted to evaluate the facility prior to licensure and ensure compliance with regulations.

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.

The visit was an office type evaluation related to a change of ownership (CHOW) application for the facility.

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.