Oakmont of Novato

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced at approximately 2PM and met with Executive Director (ED), Liza Hix to conduct a Case Management on Incident Reports received by CCL on 11/03/2023 and 11/08/2023. ED had to step away at end of visit due to a schedule conflict, Business Office Director, Tristan Amari went over report and signed. Incident Report dated 11/03/2023 Resident 1 (R1) was found by staff on floor face down stating that Resident 2 (R2) hit them. R1 sustained an injury on their left elbow and was taken to the hospital for an evaluation. Both residents reside in Memory Care. Per conversation with ED, R2 walks swiftly through facility to get exercise, and it is believed that R2 bumped into R1 causing R1 to fall down. R2 does not have a history of violent behavior and there have not been any altercations between the residents since this incident. Incident Report dated 11/08/2023 Resident 3 (R3) reported to staff that they were missing a watch valued at $200 and $50 in cash. Facility made a police report and helped R3 look for their missing items. The room was searched and missing items were not found. A phone call was made to R3s daughter who said that R3 loses things regularly and is known to find missing items in their pockets. LPA requested R3s Physicians Report that shows neither Mild Cognitive Impairment or a Dementia diagnosis. Per conversation with ED, R3 has plans to move out of facility. Should R3 decide to stay residing at facility, facility to arrange for R3 to receive an updated physicians report. No deficiencies cited during visit. Exit interview conducted, copy of report and confidential names (811) provided.the state’s words, verbatim · CDSS document, Nov 9, 2023

Allegation investigated: Staff violated residents personal rights

Licensing Program Analysts (LPAs) Cuadra and Rummonds arrived unannounced at the facility and met with Executive Director, Liza Hix to deliver findings regarding the complaint allegation above. It was alleged that Staff violated residents’ personal rights. Per Reporting party, Staff (S1) held up two fists like they were going to punch resident (R1). LPA was provided with facility internal communication records of various incidents including the incident dated 8/31/23, LPA obtained statements of incident staff (S1 and S2). S1 detailed in a daily summary report an incident that occurred on 8/31/23 around 8:05am. Per email from S1, R1 came into the lobby approached S1 to request their name. Per the statement responded, they were wearing their name badge. However, S1 inquired about the reason for R1 requesting their name, when R1 became very aggressive and S1 informed that they walked away, since R1 was making accusations about S1 that did not apply to them. Continued on LIC9099C... Unsubstantiated Continued from LIC9099... Per email from S2, R1 approached S2 stating that S1 came up to R1 with two fists in their face saying, “you better not and go tell anything to Liza”. S2 responded that they will notify their supervisor. LPA also obtained Novato Police Department service call records dated 9/1/23 at 12:45pm, there was a service call ADV – Advice to Citizen due to a possible assault from staff with a final disposition of Unfounded. However, LPA reviewed incident report logs for this facility, and it was determined that incident reports were not submitted to CCL. Administrator could not provide proof that incidents were reported to CCL. LPA will address reporting requirements on a case management inspection. Based on confidential interviews with staff and residents, LPA obtained contradictory information from the parties involved that confirmed that there was an incident that violated personal rights. Although, during LPA’s interviews with S1, LPA observed that S1 speaks in a loud tone of voice that could be interpreted as intimating for others. However, there was no supporting evidence that staff violated residents’ personal rights. A finding that the complaint allegation “Staff violated residents’ personal rights” is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Oct 13, 2023 · control 21-AS-20230901102047

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analysts (LPAs) Cuadra and Rummonds arrived at the facility to conduct an unannounced case management Legal/ Non-compliance inspection and cite deficiencies discovered during a complaint investigation met with Executive Director/acting Administrator Liza Hix. LPA was following up on items that were concerning and ensure compliance with Non-Compliance Conference dated 7/2/21: Medications – Facility had residents with unlocked medications in their possession who were not allowed to store and/or dispense medications according to physician's reports on file. At the time of inspection Medications were stored and locked at all times. During facility tour, LPAs/Executive Director observed staff (S1) crushing medications for residents in care. LPAs were informed that there are physician's crush orders on file to crush medications for some residents (R1, R2, R3, R4, R5 & R6). However, there is no crush order from a physician in R1 & R4's file. Administrator requested LPAs time to locate crush orders and email them to for review. Administrator agreed that failure to provide physician's crush order to CCL will result in a citation. LPAs need to conduct further investigation and review prior to make a final determination. Prohibited Conditions: Facility retained a resident with a prohibited condition. Facility provided resident's care notes to document daily resident's care notes and they are not maintained current month of October 2023. LPAs/Executive Director discussed the importance of documenting resident's care notes timely. Medical Assessments: Facility failed to ensure that resident's medical assessments/physician's report is complete as required. LPA reviewed 6 resident (R1, R2, R3, R4, R5 & R6) medical records including their Physician’s reports (LIC602) had been updated within 12 months as indicated per regulation. Timely Medical Attention: Facility failed to seek timely medical attention. LPA reviewed incident report logs received and residents have been assisted with timely medical attention as indicated per regulation. Continued on LIC809C... Continue from LIC809... Facility Food Services: Facility kitchen area was toured by LPA/Executive Director and LPA found that perishable foods were stored in covered containers, and the refrigerator and freezer were at a temperature within regulation. Resident Records: Facility wasn't able to provide CCLD with pre-appraisals for resident's files that were reviewed. LPA reviewed and learned that residents (R1, R2, R3, R4 and R5) records indicated that residents have been assessed for change of condition within the last 12 months per regulation. Staffing: Facility memory care didn't have adequate number of direct care staff to support each resident's physical, social, emotional, safety and health care needs. LPA/Executive Director reviewed LIC500 Personnel Summary and staff schedule for the month of October 2023. Facility has in Memory Care currently 4 care staff and 1 med tech, along with dining staff helping with meal service but not care. LPA reviewed staff training records and 2 out of 6 staff (S1 & S2) needs to receive 20 hours annual of additional training including medication training required per regulation. Reporting Requirements: Facility failed to report refusal of medications, 911 calls, suspected abuse, etc. LPA reviewed incident report logs that revealed that facility has been reporting incidents to CCL within regulations. LPAs learned through records review and interviews with Administrator that incident report logs received and found incidents not submitted timely to CCL. Per investigation conducted of complaint #21-AS-20230901102047. Also, incident report, the incident occurred on 9/20/23, but it was received at CCL on 10/4/23 which is not within 7 days of occurrence as indicated per regulation. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Appeal rights given. Exit interview conducted with Executive Director and a copy of this report was given.the state’s words, verbatim · CDSS document, Oct 13, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Oct 27, 2023

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require…(1) A written report shall be submitted to the licensing agency & person responsible for the resident within 7 days of the occurrence of any of the events…(B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirement has not been met as evidence by: Based on LPA’s records review and interviews conducted Administrator did not ensure that CCL was notified of incidents involving R1 and R7, which poses a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 13, 2023

Plan of correction: Administrator to ensure all incidents that threaten the safety of residents are reported to CCL per regulation. Signed statement that the regulation was reviewed and sign in sheet for all staff trained to be submitted by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: HSC1569.69(a)(1) · Plan of correction due date: Oct 27, 2023

§1569.69 Employees assisting residents with self-administration of medication; training requirements (a) Each RCFE licensed under this chapter shall ensure...the following training requirements: (1)...the employee shall complete 16 hours of initial training. This training shall consist of eight hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and eight hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment. This requirement is not met as evidenced by: Based on record review & interview, the licensee did not comply with the section cited above in 2 out of 6 staff which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 13, 2023

Plan of correction: Facility to submit written plan for all staff training including medication prior to assist with medications to ensure that staff has required training by POC due date.

Allegation investigated: -Failure to seek medical attention -Neglect/Lack of Supervision

Licensing Program Analysts (LPAs) Cuadra and Coppo arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with Business Office Director Tristan Amari. Regarding the allegation of Facility staff failed to seek medical attention. On 5/24/23 resident (R1) concerns were raised by outside party regarding R1's right leg position and felt that R1 was in pain, where staff was advised to take R1 to Kaiser Hospital for evaluation. Per Reporting Party, Facility med-technician was shown R1's right leg position and informed that the resident appeared to be in pain-eyes closed with intermittent groaning. On 5/24/23 R1 was diagnosed with a right distal femur periprosthetic fracture. LPA contacted Reporting Party on 5/26/23 to gather any additional information regarding incident reports or any medical issues where the facility failed to seek medical attention for residents in a timely manner. Based on interviews conducted on 7/21/23 and 7/25/23 with staff and outside parties there was a consistency of verbal statements about R1 complaining of pain since R1’s admission date in February 2023. Continued on LIC9099C... Unsubstantiated Continue from LIC9099... Facility provided correspondence between the facility and responsible party including R1’s Physician report. Based on interviews conducted with outside parties indicate that there was an active communication with the facility regarding incidents involving R1. Based on medications review, the facility obtained a PRN order for Acetaminophen -500mg for pain three times per day such medication was included into R1’s care plan dated 2/11/23 due to R1 consistency complained of pain. Also, R1’s care notes for the month of May 2023 confirmed that on 5/18/23 R1 complained of right leg pain to an outside party. However, there was no indication that any incident including falls when medical attention was not provided by the facility. A finding that the complaint allegation Facility staff failed to seek medical attention is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding the allegation of facility neglect/lack of supervision. According to Reporting Party, on 5/24/23 R1 was diagnosed with a fracture and there are concerns raised that the facility lack of supervision resulted in R1 sustaining a fracture. Based on records review, the facility provided LIC500 Personnel Summary and staff schedule for the month of June 2023. The facility has in Memory Care currently 4 care staff and 1 med tech, along with dining staff helping with meal service but not care. Based on records review, R1’s care plan indicated that residents needed assistance with full daily living activities. LPA reviewed staff training records and most of staff (S1, S2, S3, S4, S5, S6, S7, S8, S9 & S10) has received hours annual of training required per regulation. On 7/21/23 and 7/25/23 LPA conducted confidential interviews with facility staff and outside parties did not indicate any lack of supervision that resulted in R1 sustaining a fracture. A finding that the complaint allegation facility neglect/lack of supervision is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies cited during today's visit.the state’s words, verbatim · CDSS document, Aug 17, 2023 · control 21-AS-20230524142125

Type of visit: Office

An office meeting was conducted today in the Santa Rosa Regional Office via Microsoft Teams. Present in the meeting were Licensing Regional Manager Carla Nuti-Martinez, Licensing Program Manager Bethany Moellers, Licensing Program Analyst Marisol Cuadra, Executive Director Ric Pielstick, Vice President of Regulatory Sue McPherson, Vice President of Operations for Novato Mark Maclaine, Regional Health Service Director Specialist Courtney Clark, Health Service Director Specialist Kimari Pinkney and Community Marketing Director Liza Hiz. The purpose of this office meeting is to discuss Non-Compliance plan (NCC) from facility Oakmont of Novato # 216804022 which will be extended due to items of concerns about the operation of the facility not been resolved. Parties present during this call agreed to extend the Non-compliance plan until 7/2/2024. Original NCC plan went into effect 7/22/21. Ten complaints since licensure date of 6/9/2022. The Regional Office will re-review progress made on Non-Compliance Plan of one year prior to expiration date. At the time of initial Non-Compliance Conference, CCL received policies and proof of corrections for non-compliance items found during complaint investigations substantiated findings. Areas of improvement have been identified as food service, prohibited condition and reporting requirements. Areas of compliance not limited to below were discussed: - Timely Medical Attention: Facility failed to seek timely medical attention. - Staffing: 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. - Medications: Facility did not ensure that resident’s medications were properly handled, secured per resident’s physician reports on file resulting in medication errors. - Resident Records: Facility did not ensure that resident’s medical assessments and updated resident's care notes were available for review. In today's meeting, it was discussed that The Department has additional civil penalties under review.the state’s words, verbatim · CDSS document, Jul 6, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cuadra conducted an unannounced case management Legal/ Non-compliance and Annual Required inspection to this facility and met with Executive Director/Administrator Ric Pielstick. There are residents (48 AL and 31 MC) with 4 under hospice at facility. The facility serves residents with dementia and has a plan of operation for special care and programming. LPA/Administrator toured the facility around and made the following observations: Tour included resident apartments, kitchen, food storage, dining room and various common areas used by residents. Facility was a comfortable temperature and passageways were free from obstructions. Exits in memory care were equipped with delay egress that were working properly during the visit. Fire Extinguisher was found to be last charged on 09/2022 at the time of the visit. Sample test of Smoke Detectors & Carbon monoxide detector were found to be operational during this visit. Smoke detectors and fire sprinklers are annually inspected June 2023. Most recent fire/disaster drill was conducted June 2023. Resident rooms were furnished per regulation. Water temperature in various sinks accessible to residents in care measured at 115.2, 109.8 (x2), 108.3, 110.8, 114.3, 113.1, 115.3 and 114 degrees F which are within the range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Cleaning supplies are locked in supply closets as well as mobile housekeeping carts. Dangerous items were observed locked and not accessible to residents in care. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality, stored per regulation and there are residents with special diets needs that are been provided by the facility. Facility kitchen has a binder and posted on the wall with all resident’s names, pictures, and their needs. Food is available for residents any time of the day. Medications were centrally stored, locked in medication room, they were reviewed. There is a daily activity schedule for residents. At approximate 9:30am LPA/Administrator observed bathroom toilet in room# 124 needed assistance, there were feces on the toilet and bathroom floor. Administrator called staff immediately to clean the bathroom. Continued on LIC809C... Continued from LIC809... LPA initiated file review of ten staff files and ten resident files. All staff reviewed have required 1st Aid, CPR certificates and annual training hours. Administrator Certificate for Ric Pielstick 6055213740 expires 8/26/2024. LPA also followed up on items that were concerning and ensure compliance with Non-Compliance Conference dated 7/2/21: Medications – Facility had residents with unlocked medications in their possession who were not allowed to store and/or dispense medications according to physician's reports on file. At the time of inspection Medications were stored and locked at all times. Prohibited Conditions: Facility retained a resident with a prohibited condition. Facility provided resident's (R1, R2, R3, R4, R5, R6, R7, R8, R9 & R10) care notes to document daily resident's care notes. However, 8 out 10 resident's care notes have not been updated since May 2023. Timely Medical Attention: Facility failed to seek timely medical attention. LPA/Administrator pulled the call alert button that pages staff to come and assist residents with their needs. Staff responded to call button timely in rooms# 128, 124, 120 and 107 located in Memory Care area. Medical Assessments: Facility failed to ensure that resident's medical assessments/physician's report is complete as required. LPA reviewed 10 resident (R1, R2, R3, R4, R5, R6, R7, R8, R9 & R10) medical records including their Physician’s reports (LIC602) which 1 out of 10 files were not within compliance. R7's medical assessment needs to be updated. Facility Food Services: Facility kitchen area was toured by LPA/Memory Care Director and LPA found that perishable foods were stored in covered containers, and the refrigerator and freezer were at a temperature within regulation. Reporting Requirements: Facility failed to report refusal of medications, 911 calls, suspected abuse, etc. LPA reviewed incident report logs that confirmed that facility has been reporting incidents to CCL within regulations. Continues on LIC809C... Continued from LIC809C... Staffing: Facility memory care didn't have adequate number of direct care staff to support each resident's physical, social, emotional, safety and health care needs. LPA/Lead staff reviewed LIC500 Personnel Summary and staff schedule for the month of June 2023. Facility has in Memory Care currently 4 care staff and 1 med tech, along with dining staff helping with meal service but not care. LPA reviewed staff training records and most of staff (S1, S2, S3, S4, S5, S6, S7, S8, S9 & S10) has received hours annual of training required per regulation. Resident Records: Facility wasn't able to provide CCLD with pre-appraisals for resident's files that were reviewed. LPA reviewed and learned that residents (R1, R2, R3, R4, R5, R6, R7, R8, R9 & R10) records indicated that residents have been assessed for change of condition within the last 12 months per regulation. During today’s visit, LPA followed up on three incident reports occurred between 6/12/23 and 6/20/23 notifying CCL about a suspected financial abuse. First incident reported dated 6/12/23 when it was reported by resident (R1) to Administrator indicating that there were $260 missing from their apartment. According to R1, $60 were missing from a drawer in their kitchen and $200 missing from another location in the apartment. The second incident noticed by R1 was on 6/20/23, this time a missing pair of gold cabochon earrings were missing, they were last seen on 6/16/23. Staff went through the apartment and helped R1 to look for them and it was confirmed that items were missing. Responsible parties were notified including the police case# 23-2183. The last incident occurred between 6/15/23 to 6/18/23 when it was noticed on 6/18/23 by resident (R2) that there were three items missing as followed from their apartment: two platinum bands with diamonds, and one 14k gold diamond ring. The items were kept on a glass tray on the right night stand, staff once again helped searching for items unsuccessfully, the Items were last seen on 6/15/23. The facility notified responsible parties including Novato Police Department tracking #T23000276. The facility is currently conducting an internal investigation, Administrator agreed to provide a copy of their findings that are assumed to be completed by 6/30/23. However, this incident needs further investigation and review prior to make a final determination. Continues on LIC809C... Continued from LIC809C... At approximate 1:00pm LPA/Administrator observed while conducting file review that staff (S9) was not associated to the facility. LPA informed Administrator that S9 is not associated to facility and should never be working and providing care to residents prior to a criminal record clearance or exemption. *** Civil penalties are being assessed in the amount of $100 per day for allowing a person to work, reside or volunteer in the facility without a fingerprint clearance exemption. Administrator agreed to submit updates of the following documents by 7/14/2023: LIC308 Designation of Facility Responsibility, Copy of Liability Insurance, LIC 610 Emergency Disaster Plan (If changes) and Infection Control Plan (If changes) Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Appeal rights given. The Northern California/Adult Program Regional Office has scheduled an Informal meeting with Licensee and pertinent parties to follow up on areas of concerns. Exit interview conducted with Administrator and a copy of the report was given.the state’s words, verbatim · CDSS document, Jun 29, 2023

Allegation investigated: Staff did not safeguard resident's personal belongings Staff did not meet resident's incontinence needs Staff did not properly supervise resident Staff did not assist resident with showering

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. LPA met with Marketing Director and discussed the allegations. During the course of this investigation, this Department has interviewed witnesses and staff, reviewed and obtained documents, and made site visits to the facility. The following determinations are made: Personal belongings of R1, including glasses and hearing aides, were lost, stolen or misplaced while R1 was in care; Although the Licensee did not follow the required investigative and documentation requirements, it remains unknown how the belongings were removed from R1's possession; Statements made by current and former staff, as well as care note entries for R1, illustrate that when R1's spouse was not present at the facility, R1 often refused bathing and changing attempts by staff and could become agitated and aggressive; Facility care notes are kept for 30 days and not all notes were available for review. Although the allegations may be true, based on the statements and documents reviewed, there is not a preponderance of evidence to prove the allegations are or, are not, valid. Therefore, the allegations are UNSUBSTANTIATED. No citations issued. Report left. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 1, 2023 · control 21-AS-20230317123457

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.652(c) · Plan of correction due date: Jun 8, 2023

1569.652 (c). A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual, individuals, or entity contractually responsible for the fees or, if the deceased, resident paid the fees, to the resident’s estate, within 15 days after the personal property is removed. ***Based on statements/documents this requirement not met as evidenced by:R1’s refund was due 15 days after 2/25/2023 but was not made until on or about 4/20/2 **This posed an immediate violation of R1’s personal rights.the state’s words, verbatim · CDSS document, Jun 1, 2023

Plan of correction: Administration to review H&S 1569.652 and produce a signed, dated declaration which addresses how compliance with refund requirements will be met going forward. Declaration to be submitted to CCL by POC date in order to clear the deficiency

Type of visit: Case Management - Deficiencies

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on a complaint investigation. During the course of the investigation, it was learned that facility could not produce an inventory or waiver for the personal property of former resident, R1. Additionally, facility did not produce documentation that facility followed the Documentation of Loss procedures as outlined in page one of the facility’s Theft and Loss Policies and procedures when it was learned that glasses and hearing aides belonging to R1 were missing. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.the state’s words, verbatim · CDSS document, Jun 1, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87218(a)(1) · Plan of correction due date: Jun 15, 2023

87218(a)(1) Theft and Loss. The initial personal property inventory shall be completed by the licensee, and the resident, or the resident’s representative. *** Based upon statements and file research, this requirement has not been met as evidenced by: On or about April 06, 2023, facility staff were unable to produce the inventory for R1’s personal property. This posed a potential risk to the personal rights of R1.the state’s words, verbatim · CDSS document, Jun 1, 2023

Plan of correction: Administration will review the requirements of 87218(a)(1) and provide additional training to all staff providing intake to new residents. Proof of training to be submitted to CCL by POC date in order to clear the deficiency.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87208(a) · Plan of correction due date: Jun 15, 2023

87208(a) Plan of Operation. Each facility shall have... a current, written .. plan of operation. The plan.. shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval…***Based on statements and documents, this requirement not met as evidenced by: Facility did not follow Facility’s Loss policies in response to R1’s missing glasses and hearing aids. This posed a potential risk to personal rights of R1.the state’s words, verbatim · CDSS document, Jun 1, 2023

Plan of correction: Administration will review 87208 and provide additional training to staff who deal with residents’ property concerns and will proceed with their stated policy regarding R1’s missing property. Proof of training and copy of Facility’s investigative report to be submitted Report to be submitted to CCL by POC date in order to clear the deficiency.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Cuadra arrived unannounced and met with Administrator, Ric Pielstick to conduct a case management inspection regarding a recently self-reported incident at the facility, which resulted in a suspected physical abuse report. Two incident reports were received at CCL on 5/11/2023 along with SOC 341. The incident occurred on 5/6/21 after dinner when staff heard a loud smack, turned around and noticed resident (R1) walking away from resident (R2). R2 was assessed by staff who observed that R2's face appeared red and sustained a skin tear on their arm. According to the facility, this is not the first attempt of this type of incidents have happened between both residents. they have notified R1's responsible party and advised them to spend some time to observe R1's behavior which they did came to the facility for approximate two weeks between 5pm-8pm when most of the aggressive behavior towards R2 have been observed. R1's room is located directly across from R2's room. The facility have offered R1's responsible party another vacant room that is not in direct sight from R2's room. However, R1's responsible party have declined the offer. During today's visit, LPA conducted confidential interviews with staff and reviewed documents. Based on records review of R1's physician's report (LIC602) dated 6/26/22 indicates that R1 have a diagnosis of dementia without behavioral disturbance. However, R1's care plan dated 4/12/23 reflects that R1 has combative episodes that facility have notified R1's physician as indicated in documentation provided by the facility which resulted in an increase of certain medication related to behaviors. After incident, law enforcement was contacted and they came to assess the situation and could not obtain evidence to move forward with this incident. On 5/12/23 CCL have received a 3-day eviction notice issued to R1, LPA discussed with Administrator the severity of the situation which it was determined and agreed that 3-day eviction notice will be discarded, the facility will issue a 30-day eviction notice. Although, there is another facility that has assessed R1 and will be relocating them to their community. In the meantime, the facility is attempting to prevent further incidents by providing one on one staff from 7am to 9pm to assist with R1's care needs. No deficiencies cited during this inspection. Exit interview was conducted with Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, May 16, 2023

Allegation investigated: Resident(s) have sustained multiple falls due to lack of supervision. Facility staff did not dispense medication to resident as prescribed.

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. LPA met with the Administrator and discussed the allegations. During the course of this investigation, this Department has made site visits, intrerviewed staff and witnesses, obtained and reviewed documents. The following determinations are made: Complainant has not provided sufficient information regarding dates and medication names to fully investigate the medication allegation; the Department has shown that a medication for R1 was not administered as ordered on 12/1 and 12/2; There was a delay in obtaining the medication, however, which involved the Responsible Person's response in providing the medication; a review of resident falls during the approximate period of two months prior to the receipt of this complaint, does not substantiate the allegation that the falls resulted from a lack of staff supervision; High fall risk residents identified were on fall management programs; Care notes reviewed suggest appropriate staff responses to resident falls; Origins of some identified falls are unknown but sufficient evidence to link falls to non supervision was not found. Although the allegations may be true, based upon the statements, records, and lack of supporting details, there is not a preponderance of evidence to prove or, disprove, the allegations. Therefore, it is UNSUBSTANTIATED. Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 28, 2023 · control 21-AS-20230203120245

Type of visit: Case Management - Other

Licensing Program Analyst Leibert arrived unannounced for the purpose of amending a case management and citation report that was issued on 4/6/2023 by LPA Cuadra. The report was amended and a copy left at the facility.the state’s words, verbatim · CDSS document, Apr 28, 2023

Type of visit: Case Management - Legal/Non-compliance

***Amended…On 4/6/2023 during case management inspection at this facility, LPA Cuadra issued in error the wrong citation #80075 (b) due to facility failed to administer medication per physician’s orders. LPA cited the facility under General Regulations instead of citing under Residential Care Facilities for the Elderly (RCFE) regulations. LPA Leibert will amend case management LIC809 and LIC809D reports and will be issuing the citation under RCFE Regulations. Also, civil penalties issued on 4/6/2023 was dismissed. On 4/6/2023 Licensing Program Analyst (LPA) Cuadra conducted an unannounced case management Legal/ Non-compliance inspection to this facility and met with Executive Director/Administrator Ric Pielstick. LPA was following up on items that were concerning and ensure compliance with Non-Compliance Conference dated 7/2/21: Medications – Facility had residents with unlocked medications in their possession who were not allowed to store and/or dispense medications according to physician's reports on file. At the time of inspection Medications were stored and locked at all times. However, on 3/4/2023, CCL received a self-incident report notifying CCL that there was a medication error which occurred on 3/4/23 involving resident (R1) resulting in staff (S1) have received re-training on 3/5/2023 to prevent this type of incident from happening again. S1 recognized the error and contacted the physician and family. LPA was provided with S1 re-training records. Prohibited Conditions: Facility retained a resident with a prohibited condition. Facility provided resident's care notes to document daily resident's care notes. Timely Medical Attention: Facility failed to seek timely medical attention. LPA reviewed incident report logs received within 7 days as indicated per regulation. Medical Assessments: Facility failed to ensure that resident's medical assessments/physician's report is complete as required. LPA reviewed 6 resident (R1, R2, R3, R4, R5) medical records including their Physician’s reports (LIC602) which were found within compliance. Facility Food Services: Facility kitchen area was toured by LPA/Memory Care Director and LPA found that perishable foods were stored in covered containers, and the refrigerator and freezer were at a temperature within regulation. Continued on LIC809C... Continue from LIC809... Resident Records: Facility wasn't able to provide CCLD with pre-appraisals for resident's files that were reviewed. LPA reviewed and learned that residents (R1, R2, R3, R4 and R5) records indicated that residents have been assessed for change of condition within the last 12 months per regulation. Staffing: Facility memory care didn't have adequate number of direct care staff to support each resident's physical, social, emotional, safety and health care needs. LPA/Lead staff reviewed LIC500 Personnel Summary and staff schedule for the month of March 2023. Facility has in Memory Care currently 4 care staff and 1 med tech, along with dining staff helping with meal service but not care. LPA reviewed staff training records and most of staff (S1, S2, S3 & S4) has received hours annual of training required per regulation. Reporting Requirements: Facility failed to report refusal of medications, 911 calls, suspected abuse, etc. LPA reviewed incident report logs that confirmed that facility has been reporting incidents to CCL within regulations. During today’s visit, LPA followed up on a self-report SOC341 dated 4/4/2023 notifying CCL about a suspected physical abuse. The incident reported occurred on 3/31/2023 around 5pm between staff (S2) and resident (R2). Per report, the incident occurred on 3/31/23 at approximately 5:00pm when resident (R2) asked facility staff (S2) for some more lemonade, after serving it, R1 was observed upset took their cup of lemonade and water cup, poured it on the table, then took R3's cup of water and did the same thing. S2 turned around and said "don't do that R2", smacked their arm away, then R2 smacked S2 away from them. R2 continued to request more drink and kept throwing on the table for several minutes, then left the dining room. The incident was observed by S3 who file the report. Facility notified Community Care Licensing, Long Term Ombudsman and R1's responsible party about the incident and no concerns were raised by them. The facility also have conducted an internal investigation and provided LPA copies of written statement from S1, S2 and S3 describing their observations of the incident resulting in a not substantiated resolution. LPA also learned that the police has not been notified about the incident, LPA have advised the facility to cross report incident to the police department as soon as possible. LPA also conducted confidential interviews with residents and staff. However, this incident needs further investigation and review prior to make a final determination. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Appeal rights given.the state’s words, verbatim · CDSS document, Apr 6, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(5) · Plan of correction due date: Apr 7, 2023

***Amended…87465 (a)(5) Incidental Medical and Dental Care Services. The licensee shall assist residents with self-administered medications when needed. This requirement is not met as evidenced by: ***Amended…Based on incident report of 3/4/23 and interviews conducted with facility staff. Facility failed to administer medication per physician’s orders which poses an immediate health and safety risk to clients in care.the state’s words, verbatim · CDSS document, Apr 6, 2023

Plan of correction: Administrator to ensure that all residents receive their medication as prescibed by their physician. Administrator has taken disciplinary action and provided retraining to Staff. . ***Amended…civil penalties issued on 4/6/2023 was dismissed.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an inspection of the facility for a case management - other. LPA met with the Administrator of the facility, Ric Pielstick. During a tour of the facility, LPA talked with several residents (R1, R2, R3) and staff member (S1) regarding resident television volume. At the time of the inspection, the facility was clean and comfortable and residents were out and about their apartments enjoying the common areas reading, conversing, exercising. At the time of inspection there were no deficiencies found and no citations issued.the state’s words, verbatim · CDSS document, Apr 3, 2023

Allegation investigated: Facility staff do not prevent altercations between residents Facility staff are not reporting incidents to licensing

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on the above captioned complaint allegations. LPA met with the Administrator and discussed the findings. This investigation included a thorough review of resident records and other documents; interviews with witnesses and staff; site visits to the facility. The following determinations are made: R1 and R2 were involved displayed aggressive behaviors with each other on many occasions while in care at the facility; Records show that the behaviors were addressed in the residents' care plans; Residents' care notes document reasonable steps taken by staff to deal with the aggressions; Most incidents were reported as required by 87211; Two incidents which were identified as not reported may not have rose to the level of requiring a report and sufficient information to make a determination of requirement to report was not found. Although the allegations may be true, or valid, based upon the documents reviewed and statements taken, there is not as preponderance of evidence to prove the allegations or, are not, true. Therefore, the allegations are UNSUBSTANTIATED. No citations issued today. Report left. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 21, 2023 · control 21-AS-20221101155054

Allegation investigated: Resident sustained an injury due to lack of care and supervision Staff do not report incidents to resident's authorized person

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on the above captioned complaint allegations. LPA met with the Administrator and discussed the findings. This investigation included a thorough review of resident records and other documents; interviews with witnesses and staff; site visits to the facility. The following determinations are made: R1 has fallen and sustained injuries while in care; Facility incorporated fall prevention plan in R1's care plan; Record review indicateas that facility reported incidents per 87211 for R1 on a regular basis; Complainant could not provide sufficient details in order to investigatate a specific incident claimed to have gone unreported; Care notes suggest appropriate responses by care staff to R1's falls; Origins of some falls are unknown but sufficient evidence to link falls to lack of supervision was not found. Although the allegations may be true, based on statements; records and visits, there is not a preponderance of evidence to prove the allegations did or, did not, occur. Therefore, the allegations are UNSUBSTANTIATED. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 21, 2023 · control 21-AS-20221116141751

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Mar 27, 2023

87464(f)(1) Basic Services. Basic services shall at a minimum include:(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). ***This requirement has not been met as evidenced by: Based on statements and observations, R1 has been observed in need of hygiene services, in a broken wheelchair and, on one occasion, with feces under the fingernails. This posed an immediate risk to the health and safety of R1.the state’s words, verbatim · CDSS document, Mar 21, 2023

Plan of correction: Administrator will submit a written plan which will outline training plans for Memory Care staff by the Director of the MC unit. Training to address actions to be taken going forward which are intended to insure regular and documented checks of residents for hygiene and general welfare. Plan to be signed, dated and submitted to CCL by POC date in order to clear the deficiency.

Allegation investigated: Staff are not preventing resident's television from interfering with another resident's sleep

***AMENDED - Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an investigation regarding the above allegation and met with Administrator Ric Pielstick. During the investigation, LPA reviewed/obtained records, made observations and conducted interviews. It is alleged that Staff are not preventing resident's television from interfering with another resident's sleep. Resident (R1) lives in an adjoining apartment to resident (R2) and resident (R3) who share an apartment together. R1 claims that the television volume increased when R3 recently started residing with R2. LPA reviewed Appendix C (Statement of residents personal rights) of the facility house rules which state in part “ We request that all residents monitor the volume of their televisions…” Interviews with staff (S1 & S2) found that they had been asked to check the television sound level by complaint of R1. R2 stated to staff they would turn down their TV, but failed to do so. S3 stated that they observed the sound level of the television to be elevated when R1 complained to S3. Based on LPA’s review of documentation, observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. The following deficiency was cited on the attached LIC 9099-D from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided. Substantiatedthe state’s words, verbatim · CDSS document, Mar 1, 2023 · control 21-AS-20230223143406

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Mar 1, 2023

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(3)To be free from... interfering with daily living functions such as eating, sleeping, or elimination. ***This requirement was not met as evidenced by: Based on record review, interviews conducted and observations, licensee did not ensure the regulation above due to R2 and R3's occasional loud television volume which violated R1's ability to sleep. This is a potential personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Mar 1, 2023

Plan of correction: Administrator to submit a plan of action to address to CCL by POC due date of 03/07/2023.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Nakagawa conducted a case management inspection and met with Ric Pielstick, Administrator. The purpose of the case management was to follow up on three self-reported CCL received a self reported incident report on 2/12/23 for an incident that occurred on 2/10/23 when Resident (R1) exhibited aggressive behaviors. Staff were able to intervene and re-direct. CCL received a second self reported incident report on 2/17/23 for an incident that occurred on 2/17/23 when R1 exhibited some agitation and aggressive behaviors when a staff member went in their room. R1 pushed staff member and closed door. Staff was able to intervene and re-direct. Facility has increased supervision and put other methods in place to help with behaviors. CCL received a third self-reported incident report on 2/23/23 for an incident on 2/19/23. It was reported that Resident (R2) did not receive regularly scheduled medications. LPA reviewed documentation and it was documented that R2 was not able to take medication at that time; the medication was not unintentionally missed. \ No deficiencies cited at todays inspection.the state’s words, verbatim · CDSS document, Mar 1, 2023

Type of visit: POC

Licensing Program Analyst Leibert arrived unannounced for the purpose of following up on POC for citations issued January 12, 2023 as the result of a complaint and case management issues. LPA obtained the documentation for the required training of staff and will clear the deficiencies. See correction letters. In addition, LPA amended a report from prior visit to correct the omission of Administrator's name on the report. Report left. No citations issued today.the state’s words, verbatim · CDSS document, Jan 24, 2023

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced on 1/19/2023 to conduct a Case Management Legal/Non-Compliance visit. LPA was greeted by staff and screened before entry into the facility and logged in to the Visitor's Log. LPA met with Ric Pielstick, Administrator, and then went to inspect Traditions (Memory Care). Traditions has a new director, who is already setting up several training sessions. The memory care unit was clean and orderly and a comfortable temperature of 71 F. Residents' rooms varied by several degrees, depending on personal preference. Toxins were secured and not accessible to residents. Each room has a locking cupboard for storing toxins and soaps, making them inaccessible to residents. There were four (4) care staff in Traditions at the time of inspection, as well as one Activities Director, one Med. Tech. and the Traditions Director. Staffing in Traditions was adequate at the time of inspection. LPA toured the kitchen, dining room and lounge area and found the area clean and orderly. The Lounge has beer and wine, which is locked and inaccessible to residents. The Outdoor Courtyards were clean and inviting, despite all the recent rains, residents had a safe, dry space to access outside. LPA reviewed eight (8) Resident files, which were complete and up to date. All staff present at the facility were fingerprinted and associated. During this inspection, LPA followed up on an incident report that was submitted on 11/26/2022 which involved a medication error which occurred on 11/25/22 at 10 AM. The staff member (S1) recognized the error and contacted the physician and family. (Continued on 809-C) (Continued from 809) During this inspection, LPA followed up on an incident report that was submitted on 11/26/2022 which involved a medication error which occurred on 11/25/22 at 10 AM. The staff member (S1) recognized the error and contacted the physician and family. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Administrator and Appeal rights were given.the state’s words, verbatim · CDSS document, Jan 19, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 80075(b) · Plan of correction due date: Jan 19, 2023

80075(b) Health Related Services. Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement is not met as evidenced by: Based on incident report of11/26/22 and interview withmedical staff at facility, 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.the state’s words, verbatim · CDSS document, Jan 19, 2023

Plan of correction: Administrator/Licensee to ensure that all clients receive their medication as prescibed by their physician. Administrator has taken disciplinary action and provided retraining to Staff. Additionally, continuing a training on 1/26/23. A list of attendees and training materials will be submitted to LPA by 1/28/23. A

Allegation investigated: Facility vaccinated a resident without obtaining permission from resident's responsible party. ****This is an amended version of the original report*****

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. LPA met with Ric Pielstick and discussed the findings. During the course of this investigation statement were taken, site visits made, and documents obtained and reviewed. The following determinations are made: R1 has a designated responsible person; On or about October 27,2022, facility provided flu shot clinic for residents conducted by outside vendor and on facility premises; R1 received a vaccine at the clinic on 10/27: Responsible person for R1 did not consent to the procedure and, in fact, declined the vaccine in preference to obtaining the vaccine for R1 at a later date due to a recent medical procedure undergone by R1. Based upon the records reviewed and statements taken, the preponderance of evidence standard has been met. Therefore, the allegation is SUBSTANTIATED. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided. Copy of report left. Substantiatedthe state’s words, verbatim · CDSS document, Jan 12, 2023 · control 21-AS-20221130172055

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(8) · Plan of correction due date: Jan 16, 2023

Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: …To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. ***Based on statements and documents, this requirement has not been met as evidenced by: Facility sponsored flu shot clinic where R1 obtained vaccine without personal representative’s knowledge or consent. This posed an immediate risk to R1’s health and personal rights.the state’s words, verbatim · CDSS document, Jan 12, 2023

Plan of correction: Administration shall provide written protocols for staff to follow when outside vendors provide medical services to residents at the facility and will provide a schedule for staff training on the issue. Administration will provide this documentation to CCL by POC date in order to clear the deficiency.

Type of visit: Case Management - Deficiencies

During the course of a complaint investigation, LPA Leibert observed a bottle of finger nail polish remover which was not secured and located in the Memory Care bathroom of apartment 121. LPA removed bottle and gave it to the MC Director who indicated that she would provide additional refresher training for staff. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.the state’s words, verbatim · CDSS document, Jan 12, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Jan 18, 2023

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. ***Based on LPA observation this requirement has not been meet as evidenced by: finger nail polish remover was observed in bathroom of memory care apartment bathroom which was accessible to residents in care. This poses an immediate risk to the health of the residents.the state’s words, verbatim · CDSS document, Jan 12, 2023

Plan of correction: Director will provide refresher training to MC staff and will provide proof to CCL by POC date in order to clear the deficiency.

Allegation investigated: Resident sustained multiply injuries due to a fall during a transfer

Licensing Program Analyst s(LPAs)Bertozzi and Nakagawa arrived unannounced to the facility to deliver findings regarding the complaint allegation above and met with Business Office Manager, Tristan Amir. Executive Director Ric Pielsitck was available by phone. Resident sustained multiply injuries due to a fall during a transfer - Complaint alleges that resident was handled roughly by a caregiver because they attempted to transfer a resident by themselves resulting in multiple injuries. Per care plan, involved resident was a two person transfer and through interview, LPA confirmed that caregiver transferred resident by themselves. Review of chart notes and special incident report indicated that resident did sustain a skin tear and a head laceration and was treated at the hospital. Continued on LIC9099C Substantiated Continued from LIC9099 Based on LPAs observations and record reviews, the preponderance of evidence standard has been met, therefore allegationsthat resident sustained multiply injuries due to a fall during a transfer are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 8), are being cited on the attached LIC 9099D.”) The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided. Continued from LIC9099A Uncleared adults providing care - Based on review of Employee Roster provided by facility there is one staff who is not fingerprinted. Staff works in culinary and does not provide direct care to residents. Three other staff were identified as being cleared but not associated to the facility. Allegations that Administrator did not report unusual incident as required, Facility is not addressing the mold issue and Uncleared adults are providing care are unsubstantiated meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the allegation occurred. No deficiencies cited.the state’s words, verbatim · CDSS document, Dec 22, 2022 · control 21-AS-20221102125316

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Dec 22, 2022

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based on records reviewed, interview, staff transferred R1 by themself, rather than by 2-person assist as required in careplan, which poses an immediate risk to their health, safety, personal rights for residents in care.the state’s words, verbatim · CDSS document, Dec 22, 2022

Plan of correction: Facility to provide planned training date for designated carestaff to review the proper care and supervision following careplans according with Title 22 Regulation. Facility to submit Department with proof of training date by 12/23/22 and subsequent proof of training with staff signatures, date, time and what was covered in addition to self certification that facility undestands this regulation by POC due date of 01/09/23.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst s(LPAs)Bertozzi and Nakagawa met with Business Office Manager, Tristan Amir to address deficiencies that were noted during a complaint investigation. Executive Director Ric Pielsitck was available by phone. During a complaint investigation LPAs were provided an Employee Roster and LPAs learned that facility has one staff who is not fingerprinted and three other staff were identified as being cleared but not associated to the facility. Immediate Civil Penalties are being assessed in the amount of $400 due to one staff not being fingerprinted and three staff not being associated to the facility. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.the state’s words, verbatim · CDSS document, Dec 22, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(g) · Plan of correction due date: Dec 23, 2022

87411 Personnel Requirements (g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall.... This requirement is not met as evidenced by: Based on document review 1 staff have not been fingerprinted and 3 staff have not been associated which poses an immediate risk to the health, safety, personal rights for residents in care.the state’s words, verbatim · CDSS document, Dec 22, 2022

Plan of correction: Facility to have all staff fingerprinted and cleared prior to having staff returning to work. Facility to submit self-certification that all staff will be be fingerprint-cleared and associated to faciity by POC due date of 12/23/22.

Allegation investigated: Facility did not provide resident's records to responsible party.

Licensing Program Analyst (LPA) Cuadra arrived unannounced to the facility met with Executive Director (Administrator), Ric Pielstick to deliver findings regarding the complaint allegation above. It was alleged that the facility did not provide resident’s records to responsible party. Per Reporting party alleged that facility staff is not allowing authorized representative to obtain resident’s (R1) records. Based on records review, on 8/17/22 R1 signed an authorization for a legal services firm to represent and obtain R1’s records. On 8/26/22 facility received a request from law firm representing R1 requesting a copy of resident’s records. Based on confidential interviews, LPA was informed by facility Legal Department that the records were released to R1’s responsible party as of 11/3/2022 after confiming the validity of the legal services firm to represent R1. Based on information received by the facility Legal Department and reporting party, it was confirmed that records were provided to R1’s responsible party. A finding that the complaint allegation “Facility did not provide resident's records to responsible party” is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Unsubstantiatedthe state’s words, verbatim · CDSS document, Nov 15, 2022 · control 21-AS-20220919203355

Type of visit: Case Management - Legal/Non-compliance

LIcensing Program Analyst (LPA) Jill Nakagawa arrived at 1:00 PM and conducted an unannounced random required non-compliance inspection of the facility. LPA met with Executive Director Ric Pielstick. LPA toured the building and grounds with Executive Director and found the facility to be clean and in good repair. LPA did a room inspection of the Traditions/Memory Care Unit and found all the bathrooms were equipped with necessary grab bars and non-slip floors/mats. Residents were eating lunch in the dining room, with care staff and servers attending the residents with their meals. LPA reviewed 6 resident records (R1 -R6) which showed that 4 out of 6 residents' 602's were not complete, so Medical Assessments will need to be completed as stated on attached 809-D At the time of inspection Medications were stored and locked at all times. There have been no medication errors since the NCC of 6/14/2022. There were no residents with any Prohibited Conditions at the time of inspection. Resident Records were reviewed and appeared to be in order. At the time of inspection staffing in Memory Care currently has 4 care staff and 1 med tech, along with dining staff helping with meal service but not care. LPA requested Memory Care Schedule for the last 3 months. Food Service was inspected and LPA found that perishable foods were stored in covered containers, and the refrigerator and freezer were at a temperature within regulation. LPA requested proof of staff training by certified staff on food handling and storing. The following deficiency were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6, Ch. 8 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.the state’s words, verbatim · CDSS document, Oct 20, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87458(a) · Plan of correction due date: Oct 20, 2022

87458(a) Medical Assessment. Prior to accepting a person as a resident the licensee must obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. ** This requirement was not met. Based on LPAs record review he facility failed to ensure Residents (R1-4) had submitted a completed medical assessment, within the last year. R1 -R4 did not sign Physician's Report which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 20, 2022

Plan of correction: Licensee agrees to review resident records and make sure they are complete and signed by POC due date of 11/01/2022.

Allegation investigated: Facility is not following resident's care plan. Facility staff did not respond to resident's alarm. Facility staff did not dispense resident's medication as prescribed.

The Department conducted a complaint investigation regarding the allegation listed above. Licensing Program Analyst Fernandes-Goes arrived unannounced for the purpose of closing the investigation and met with xxxxx. On August 3rd, 2022, LPA Fernandes-Goes toured the facility; conducted interviews; acquired documentation; and made observations of the facility. During investigation conducted, Department tour facility and made observations, conducted interviews on 8/1/2022, 8/3/2022, 8/8/2022, 9/22/2022, & 9/23/2022; and reviewed documentation submitted. Continued LIC 9099-C Substantiated Department has learned that resident’s R1 LIC 602s (physician’s assessment) dated 9/11/2020 & 6/16/2022 states dementia, sundowning & wandering behavior, sleep apnea, able to communicate needs, and able with assistance to do the following bathe self, dress/groom, feed, care for own toileting needs. In addition, care plans 12/15/21 states “requires stand by assistance with s/set up and performance of grooming tasks (28 points); 3 to 4x/week showers (10 points); requires stand by assistance with dressing and undressing 2x/day (31 points)” and care plan 6/13/2022 states “requires stand by assistance with s/set up and performance of grooming tasks (28 points); 1 to 2x/week showers (13 points); requires hands on assistance with dressing and undressing 2x/day (37 points). Department has learned that picture taken by POA on July 19, 2022 shows resident R1 with an extremely red groin rash and stated that resident R1 was being found with same clothes when visiting consecutive days. Facility staff stated, “that resident was refusing showers” and has no shower or changing record logs. In regard to staff not assisting resident with hygiene needs, at this time Department can’t prove or disprove that it has occurred. In regard to, “Facility staff did not ensure resident's bathroom was sanitary.” Department has learned that facility has the following number of staff in memory care per shift AM 4 care staff & 1 med tech, PM 4 care staff & 1 med tech, and NOC 2 care staff & 1 med tech. According with MC Director Juan Ferrel interview “There is a person designated for housekeeping in Memory Care” which are not caregivers. “Care staff do the bed, light cleaning, and pick up clothes on the floor, make sure that bathrooms are clean. If bathrooms are not clean, they contact housekeeping. Housekeeping change sheets on beds onn the housekeeping days assigned for the room. In the case of an accident care staff will change sheets and placed them to wash. Care staff still does the laundry for residents.” During visit to facility on 8/3/2022, LPA toured the facility and randomly observed bedrooms/bathrooms and found facility clean. There is not sufficient evidence for the Department to prove or disprove that residents bathrooms were not sanitary. Continued LIC 9099-C Department investigated allegation “Facility failed to follow admission agreement”, resident R1 admissions agreement signed on 10/ 2020 states that “b. (pg 9) Amount of Refund - within thirty (30) days after your apartment has been vacated and your property has been removed from it, Oakmont shall pay you or your responsible party a refund of any prorated unused portion of your final monthly fee payment…”. According with records reviewed and interviews, facility provided a refund to resident R1/POA on August 17, 2022. Amount refund was based on care plan, care fees, and rent fees. Based on records reviewed and interviews, Department can not prove or disprove that facility didn’t follow admission agreement at this time. A finding that the complaint allegations of “Facility staff did not assist resident with hygiene needs.”; “Facility staff did not ensure resident's bathroom was sanitary.”; “Facility failed to follow admission agreement.” are unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies cited during this inspection. Department has learned that resident R1 was admitted under assisted living in October 2020, however; moved into memory care on July 2021. LIC 602s (physician’s assessment) for resident R1 dated – 9/11/2020 & 6/16/2022 states dementia, sundowning & wandering behavior, sleep apnea, able to communicate needs, and able with assistance to do the following bathe self, dress/groom, feed, care for own toileting needs. In addition, care plans provided by facility states the following: • Care plan 12/14/20 states requires set up and/or assistance with clothes 1x/day (15 points); breathing treatments – resident requires staff observation and assistance 1 to 2 times per day (8 points) Det up CPAP machine. Machine in night stand and hose in closet. Ensure it is plugged in, nose piece attached to hose and plastic container is filled with water – observe/report breathing treatments. Maintain safe/clean environment. • Care plan 12/15/21 states requires stand by assistance with s/set up and performance of grooming tasks (28 points); 3 to 4x/week showers (10 points); requires stand by assistance with dressing and undressing 2x/day (31 points); requires a fall management program due to fallen within the past year (16 points); breathing treatments – resident requires staff observation and assistance 1 to 2 times per day (15 points); status checks – resident doesn’t require status checks (0 points) • Care plan 6/13/2022 states requires stand by assistance with s/set up and performance of grooming tasks (28 points); 1 to 2x/week showers (13 points); requires hands on assistance with dressing and undressing 2x/day (37 points); requires a fall management program due to fallen within the past year (16 points); breathing treatments – resident requires staff observation and assistance 1 to 2 times per day (15 points); status checks – resident doesn’t require status checks (0 points) According to facility “Instructions” on care plans specified above, Breathing Treatments for care plans 12/15/21 & 6/13/22 – states “Resident requires staff observation and assistance 1 to 2 times per day.” With the following instructions “Assist resident with setting up CPAP machine in the evening around 8:30 – 9pm. This includes filling the cage with water, hooking the hose up, and turning it on. Continued LIC 9099-C Remove from apartment and clean during the day – store in med room. Resident ‘R1’ has tendency to hide pieces if left in apartment. The PM shift will bring to ‘resident R1’ around bedtime and assist with set up. Overnight shift will need to check in and see that ‘R1’ is still wearing it during the night.” – CPAP discontinued on 6/23/2022 by doctor’s orders. Furthermore, CPAP discontinued order dated 6/23/22 from resident’s R1 doctor however, POA for resident R1 states that they were never contacted regarding requesting doctor to discontinue this order. Facility only communicated the decision after the fact – emails between facility and family members states family members questioning decision made by facility to fax doctor to discontinue CPAP orders. According to family and POA the doctor that prescribed CPAP was a pulmonologist who had also diagnosed R1 with COPD and sleep apnea. Email from Kathleen O. Acting ED to family members on June 22, 2022 at 4:02 PM state “…we established is that for the next 7 days we will have a companion with ‘R1’ from 8pm-8am. At that time that person will be observing her to see her sleep patterns and to redirect her with her Cpap.” However; facility staff on June 22, 2022 at 5:30 PM faxed R1’s doctor stating “Could you please review the Cpap treatment and possibly “discontinue” or write an alternative treatment?” Family and POA was never informed that doctor had been contacted to discontinue CPAP order. Family wasn’t informed until 6/24/22 that doctor had agreed to discontinue the CPAP. MARs (Medication Administration Records) show that July there wasn’t an order for CPAP and June 2022 was done until 6/24/22. Facility states that “they are not to help with CPAP and has no policy or procedure for that.” Between June 3rd and June 21st of 2022 resident 14 times did not receive the treatment due to missing parts of the machine in addition of 2 times that resident refused. Doctor’s order for 2/14/2022 and 1/7/2022 states that “breathing machine at bedtime; ensure it is plugged in, nose piece attached to hose and plastic container filled with water and to be kept in medroom.” Based on documentation reviewed, facility failed to follow doctor’s orders and care plan as it was agreed upon and monthly charged. Continued LIC 9099-C Moreover, Resident R1 had a fall in an apartment for another resident on 7/22/2022 – per facility interviews around 11:30 PM – per sensor alarm record log resident’s R1 sensor went of on 7/22/22 at 9:01 PM, 9:09 PM, and 10:44 PM. Facility stated that resident R1 was found at resident’s R2 apartment around 11:30 PM on 7/22/22 – Resident’s R2 sensor alarm went off on 7/22/22 at 8:11 PM, 8:29 PM, 9:15 PM, 9:33 PM, and 9:50 PM according with record log provided by the facility. ED stated that “Since Nov/Dec of 2021, the system has been on 24/7” According with care plan 12/15/2021 & 6/13/2022, facility was aware that “Resident wakes up on some nights but is easily redirected back to bed after ADL needs are met”, “Resident wanders only within the common areas of the secured community”, and “Resident has fallen within the past year and requires a fall management program”; however, facility staff failed to respond when motion sensor went off and resident R1 wandered into another residents room and had a fall. According with complaint allegations “Facility is not following resident's care plan.”; “Facility staff did not respond to resident's alarm.”; and “Facility staff did not dispense resident's medication as prescribed.” there were related observations made during visit. Based on LPAs' observations and interviews which were conducted and documentation reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Appeal of Rights Given. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.the state’s words, verbatim · CDSS document, Sep 29, 2022 · control 21-AS-20220727103847

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Oct 13, 2022

87411(a)Personnel Requirements This requirement isn't met as evidenced by: Based on interviews & records facility didn't comply w/section above resident R1 careplan needs which poses a risk to health, safety, personal rights of resident in care. Department learned that R1 has a care plan dated 12/15/21 & 6/13/22 states breathing treatment needs & fall management plan that were not followed (see LIC 9099)the state’s words, verbatim · CDSS document, Sep 29, 2022

Plan of correction: Facility to ensure that resident's needs are met accoding to careplan and doctor's orders. Facility agrees to submit Department with a plan on how they will ensure that residents services will be met as needed and based on docs orders by POC date of 10/13/2022 in order to clear this citation.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(2) · Plan of correction due date: Oct 13, 2022

87468.1(2) Persoanl Rights This requirement isn't met as evidenced by: Based on interviews & records facility didn't comply w/section above R1 had a fall on an apartment of another resident on 7/22/22 sensor alsarm record went off 3 different times during PM shift for R1; R1 was found in another resident's room and sent out to ER. Facility was aware resident wakes up and needs to be redirected during the night.(see LIC 9099 and docs)the state’s words, verbatim · CDSS document, Sep 29, 2022

Plan of correction: Facility to ensure that residents are to be accorded safe, healthful and comfortable accommodations, furnishings and equipment. Facility to submit Department w/ self certification that careplans have been reviewed and staff understands/knows residents needs by POC date of 10/13/2022 in order to clear this citation.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(c)(2) · Plan of correction due date: Oct 13, 2022

87465(c)(2) Incidental Medical and Dental Care. This requirement is not met as evidenced by: Based on interviews, record reviews,facility didn't comply w/section above in 1 out 1 resident which poses a potential risk to resident in care. Resident R1 care plan 6/13/22 requires breathing treatments according with doctor's orders. However, MARs show that between Junde 3 & June 21/2022 resident R1 14 x din't receive treatment due to missing parts of a machine(see9099,docsthe state’s words, verbatim · CDSS document, Sep 29, 2022

Plan of correction: Facility to submit Department with self certification that all residents under care will have their doctor's orders followed as prescribed and that staff understand these orders by POC due date of 10/13/2022.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Fernandes-Goes arrived unannounced with the purpose of closing a complaint investigation. During subsequent complaint investigation LPA learned that there are related deficiencies observed during the visit. LPA met with Ric Pielstick - Executive Director. Following item was observed during investigation visit: Department has learned that resident R1 had a fall on 7/22/2022 and R1 was sent to the ER, however; incident report was not provide/submitted to Department until LPA was visiting facility on 8/3/2022. In addition, Resident R2 had a medication refusal on 8/3/2022 that wasn’t reported to the Department. It was learned while reviewing records. (see records, LIC 809-D) Appeal of Rights Given. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.the state’s words, verbatim · CDSS document, Sep 29, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211 · Plan of correction due date: Oct 13, 2022

87211 Reporting Requirements. This requirement is not met as evidenced by: Based on records reviewed, interview, facility didn't comply w/section cited above within 2 of2 residents incident reporting which poses a potential risk to their health, safety, personal rights for residents in care. Resident R1 and R2 had incidents that occurred on 7/22/22 & 8/3/22 which were not submitted to the department. (see docs, LIC 809)the state’s words, verbatim · CDSS document, Sep 29, 2022

Plan of correction: Facility to provide training to designated reporting staff to ensure that all incidents that need to be reported will be reported according with Title 22 Regulation. Facility to submit Department with proof of training, staff signatures , date , time and what was covered in addition to self certification that facility undestands this regulation by POC due date of 10/13/22.

Type of visit: Office

Licensing Program Manager Bethany Moellers, Licensing Program Analyst Carla Fernandes-Goes met with Ric Pielstick - Executive Director, Sue McPherson - VP of Regulatory , Mark Maclaine - Vice President of Operations for Novato, Jennifer Sato - Regional Health Service Director Specialist. This meeting was conducted virtually due to COVID-19. This meeting is being conducted to ensure that Executive Director is aware and understands non-compliance plan in place and review documentation that is required from facility under # 87211 Reporting Requirements. Facility understands that internal documentation can be requested by the Department based on Title 22 Regulations. In addition, it was discussed the importance of making sure that all necessary incidents are reported and in a timely matter. The licensee was informed that additional civil penalties are under review by the Department per Health and Safety Code 1569.49 (f) due to substantiated complaint #21-AS-20210310171803 & one more under Priority 1 complaint under investigation for formal facility #216803904 Oakmont of Novato. There were no deficiencies cited at this time.the state’s words, verbatim · CDSS document, Aug 25, 2022

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Fernandes-Goes arrived to conduct a case management visit regarding incident report submitted to Community Care Licensing (CCL) for resident R1 which occurred on 7/30/2022. LPA met with Ric Pielstick - ED. Per facility resident R1 AWOL/eloped while under facility responsibility. Resident R1 has a physician's report dated 6/8/2022 diagnostic of dementia and states that resident is NOT able to leave facility unassisted at any time. Resident R1 lives in the assisted living part of facility. Per facility staff resident R1 had her wander guard self removed and walked out of the facility and was found by staff at Grocery Outlet. (see confidential name list, copies, LIC 809-D) Since this incident, facility has reassessed resident R1; discussed plan of care with family; conducted staff in-service for elopement and facility elopement policy and procedure which have been handled to the Department as prove of correction; and elopement drill has been scheduled. (copy on file) Resident R1 will be moving out of the community. At this time resident has escort service and every 2 hrs. check. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided. Appeal of Rights Given.the state’s words, verbatim · CDSS document, Aug 3, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(b)(2) · Plan of correction due date: Aug 4, 2022

87705(b)(2)Care of Persons with Dementia - Safety measures to address behaviors such as wandering.This requirement isn't met as evidenced by:Based on interviews,SIR & physician's report R1 eleoped w/out staff knowledge on 7/30/22 the facility didn't comply w/section above to address behaviors such as wandering for resident R1 which poses an immediate Health, Safety risk to residents in care. (see copies)the state’s words, verbatim · CDSS document, Aug 3, 2022

Plan of correction: Facility agreed and conducted in-service staff training regarding elopment and have facility elopement policies and procedures reviewed and in place. Both have been handled to CCLD on 8/2/2022. POC cleared

Type of visit: Post Licensing

License Program Analyst (LPA) Fernandes-Goes arrived unannounced to conduct a Non-Compliance Post Licensing Infection Control inspection to this facility. LPA was welcomed by front desk staff Emily who contacted Memory Care Director (MCD) Juan Ferrel and ED Ric Pielstick. There are 83 residents (52 AL and 31 MC) with 3 under hospice at facility. Facility has activities planned for residents during the day. LPA arrived at the facility and had her temperature checked and logged. During facility tour on 07/21/2022 with MCD Juan; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Exits in memory care were equipped with delay egress that were working properly during the visit. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 09/2021 at the time of the visit. Sample test of Smoke Detectors & Carbon monoxide detector were found to be operational during this visit. Smoke detectors and fire sprinklers are annually inspected. Hot water temperature measured between 107.2 degrees F and 119.3 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 6 out of 6 residents' bathroom faucet while touring facility. The facility serves residents with dementia and has a plan of operation for special care and programming. There is a daily activity schedule for residents. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of visit. LPA learned that there are provisions made for residents with special dietary needs. Facility kitchen has a binder and posted on the wall with all resident’s names, pictures, and their needs. Food is available for residents any time of the day. Toxins are stored in a locked cabinet inside the laundry area. Dangerous items were stored inaccessible to clients. There was a supply of cleaners, hygiene products and paper products available for clients. All resident’s bedrooms have lighting & appropriate furnishings. Continued LIC 809-C A review of six resident records as well as two resident’s medications was conducted. LPA reviewed resident’s files and learned that 6 of 6 residents have an updated re-appraisals/needs & care plans and physician’s assessments (LIC 602A). Infection Control: Facility has submitted a mitigation program plan that has been approved. Some posters have been placed at entrance and common bathrooms. Facility has hand sanitizer available for visitors. Staff before coming into work have temperature checked. Facility has PPE supply stored in memory care storage area. There has been new staff hired and new resident’s admission since COVID. Residents’ medications are stored and locked in medication room inside medication cart. Facility has a 30-day supply of medication for clients. Residents are not wearing masks inside the facility, however; staff stated that they are able to wear masks when going on outings. All staff had masks on during this visit. In addition, facility is allowing visitors inside after temperature check. Residents have available virtual and telephone calls when contacting with family members and others. Staff have had all PPE training required on file and have acquired N-95 fit testing for staff. There were no deficiencies cited at this time. Department is requesting facility to submit the following update documents by 07/28/2022 to the Department: LIC 308 Designated LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan LIC 610E-S Supplemental Emergency Disaster Plan for RCFE LIC 9020 Register of Facility Client’s/Resident’s Copy of Certificate of Liability Insurance Copy of last annual Smoke detectors and fire sprinklers inspectionthe state’s words, verbatim · CDSS document, Jul 21, 2022

The state marks this report as 4 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Office

Licensing Program Manager Bethany Moellers, Licensing Program Analyst Carla Fernandes-Goes met with Kathleen Olson - Acting Executive Director, Sue McPherson - VP of Regulatory , Mark Maclaine - Vice President of Operations for Novato, Jimmy Duong - Regional Health Service Director Specialist. This meeting was conducted virtually due to COVID-19. This meeting is being conducted to transfer a Compliance Plan Conference which started on July 2, 2021 due to facility new ownership. The following concerns were identified by the Licensing Agency in regard to the operation of this facility including but not limited to: Complaint investigations that have been substantiated and other concerns that have been observed such as: Ø Medications: Facility had residents with unlocked medications in their possession who were not allowed to store and/or dispense medications according to physician's reports on file. Ø Prohibited Conditions: Facility retained a resident with a prohibited condition Ø Timely Medical Attention: Facility failed to seek timely medical attention. Ø Medical Assessments: Facility failed to ensure that resident's medical assessments/physician's report is complete as required. Ø Resident Records: Facility wasn't able to provide CCLD with pre-appraisals for resident's files that were reviewed. Ø Staffing: Facility memory care didn't have adequate number of direct care staff to support each resident's physical, social, emotional, safety and health care needs. Ø Facility Food Services: Ø Reporting Requirements: Facility failed to report refusal of medications, 911 calls, suspected abuse, etc. The Regional Office will re-review progress made on Non-Compliance Plan of 2 years from July 2, 2021. Continued LIC 809-C The licensee was informed that additional civil penalties are under review by the Department per Health and Safety Code 1569.49 (f) due to substantiated complaint #21-AS-20210310171803 & # 21-AS-20210823100922 under formal facility #216803904 Oakmont of Novato. There were no deficiencies cited at this time.the state’s words, verbatim · CDSS document, Jun 14, 2022

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Fernandes-Goes conducted a pre-licensing inspection and met with Acting Executive Director Kathleen Olson. Fire clearance has been approved for 110 non-ambulatory and 8 bedridden residents by the Marin County Fire Department. LPA will conduct a component III orientation with Kathleen Olson – Acting ED and Juan Ferrel – Traditions Director. There is a total of 87 residents with 32 residents in memory care. There are 6 residents currently on Hospice. LPA toured the facility on 4/6/2022 with Acting Executive Director Kathleen Olson; facility was found to be at a comfortable temperature with all exits free from obstruction. Facility is a two- story building in good repair and at a comfortable temperature. The main floor includes kitchen, dining area, activities area, bar and lounge, lobby, fitness area, beauty salon, bistro, reading room, living room, laundry room, office rooms, medication room, Traditions (memory care) and Assisted Living resident's bedrooms. Second floor includes media room, staff room, emergency food supply, assisted living resident's bedrooms. All residents' bedroom has their own bathroom. Traditions has 7 double bedrooms. Facility has several different activities available for residents as desired and has an activity calendar posted. There is outdoor space for activities. Menus for dining are posted on the table and at entrance. LPA observed that provisions are made for individuals with special dietary needs. Special diets are posted on a kitchen board with pictures and Traditions have a binder for special diets. Food stored in the kitchen refrigerator were properly stored as per regulations. Toxins are locked in chemical room on first floor. Facility also has community restrooms downstairs. There was a supply of cleaners, hygiene products and paper products available for residents. All bathrooms designated for residents at the facility were supplied with paper towels and hand soap dispensers. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. A sample tour of resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing. Mattress pads are available for residents. Continued LIC 809-C Most postings noted to be current and in compliance with guidelines w/ only few missing. Locked cabinets for sharps and daily used toxins in Traditions were inaccessible to residents' in care. First aid kit was observed. PPE is stored in a storage room in memory care area. Exits were free from obstructions at the time of the visit. Fire Extinguisher was found to be last charged on 9/2021. Facility smoke detectors are hard wired and sound directly to the fire station. Smoke detectors and fire sprinklers are inspected annually. LPA observed single smoke and carbon monoxide detectors that were found to be operational. There are emergency lights in many of the fixtures in the common areas of the facility that come on should a power outage occurs. Hot water temperature measured between 102.5 degrees F and 118.5 degrees F falling out of Title 22 acceptable regulation of 105.0 to 120.0 degrees F required hot water temperature in 2 of 9 resident’s bathroom faucets. The facility has special care plan of operation and programming for residents with dementia. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Facility understands that Disaster Drillsmust be conducted at least quarterly. Acting ED Kathleen stated that all staff is trained when hired on emergency preparedness and is aware were to shut off power, water, and so on. Facility has been advised to place a facility sketch with location of shut off power, water, and so on in a designated place that staff can see and located if needed. Oakmont of Novato license # 216803904 has been licensed under OMG II INC and Oakmont of Novato LLC with following members Courtney Siegel, Crystal Dillard, CFO Kimberly Hynk and Susan McPherson. New Oakmont of Novato pre-license # 216804022 has as licensee Oakmont Management Group LLC OPCO and operating Agreement under Oakmont Management Group LLC with the following managers Courtney Siegel, Crystal Dillard, Matthew Stevenson, and Molly Flater. Oakmont of Novato license # 216803904 at this time has 6 complaints pending investigation and 8 complaints closed – 7 substantiated and 1 unsubstantiated. From these 8 complaints, 2 complaints # 21-AS-20210310171803 & # 21-AS-20210823100922 have additional civil penalties that are under review by the Department per Health and Safety Code 1569.49 (f). Facility number # 216803904 will remain open until all complaints are closed and civil penalties are reviewed. In addition, facility is under a 2 year non-compliance plan implemented on July 2, 2021 under facility # 216803904 will carry over to new license # 216804022 when approved and issued by the Department. Continued LIC 809-C Community Care Licensing has requested the following item be corrected prior to licensure: - Provide a picture showing that the following postings have been placed in the facility: Non-Discrimination, Rights of Residents' Council, Theft & loss facility policy, COVID social distancing, symptoms, and coughing etiquette. - Provide proof that hot water temperature is within Title 22 Regulations. - 5 day hot water temperature log. - Facility provided Mitigation Plan that has been previously reviewed with changes that have been made by facility during this visit. Mitigation plan will be evaluated by Department prior to licensure. There were no deficiencies cited at this time.the state’s words, verbatim · CDSS document, Apr 6, 2022

The state marks this report as 8 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Office

Facility Type: RCFE Application Type: CHOW Capacity: 0118 Census (if any clients in care): COMP II by CAB successfully completed Method: Telephone call COMP II Participant: ANNEMARIE DOMIZIO Applicant/administrator participated in COMP II via telephone call with the analyst at CAB. Identification of the applicant and administrator was verified by photo ID . During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Staff qualifications and responsibilities 3. Applicant and Administrator qualifications 4. Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions 5. Grievances, Complaints, Community resources 6. Physical plant, food service 7. Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of propertythe state’s words, verbatim · CDSS document, Mar 1, 2022