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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803998
Report Date: 01/14/2025
Date Signed: 01/14/2025 04:19:40 PM

Document Has Been Signed on 01/14/2025 04:19 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:OAKMONT GARDENSFACILITY NUMBER:
496803998
ADMINISTRATOR/
DIRECTOR:		MORGAN HOLIENFACILITY TYPE:
740
ADDRESS:301 WHITE OAK DRIVETELEPHONE:
(707) 921-1861
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY: 79CENSUS: 47DATE:
01/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:04 AM
MET WITH:Morgan Holien, Administrator TIME VISIT/
INSPECTION COMPLETED:
04:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Administrator Morgan Holien Administrator Certificate 6064643740 expires 3/25/26.

At approximately 9:30am LPA and Admin toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered. In addition to open items being covered, LPA discussed with Admin that all opened items should also be labeled with date of opening. LPA and Admin observed disinfectants and cleaning solutions in unlocked cabinet in ancillary Assisted Living Dining room (deficiency cited, see 809D). Hot water temperature was within regulation at 123.6 degrees F; however, LPA, chef, and Admin discussed putting up warning signs of water temperature over 125 degrees F as a precaution.

Facility has Independent Living (IL) and Assisted Living (AL) residents. Facility does not offer Memory Care. LPA toured selected AL resident rooms: #149, #151, and #161. All bedroom bathrooms were equipped with an emergency pull cord and grab bars. Water temperature in sink accessible to residents in care measured at 116.2 degrees F in room #149, 113.8 degrees F in room #151, and 117.1 degrees F in room #161, which are within the allowable range of 105 to 120 degrees F.

Fire extinguishers were last inspected 12/7/24. Smoke/Carbon Monoxide detectors located throughout the facility are hardwired, last serviced by vendor on 10/29/24. Facility’s last quarterly disaster drill was conducted 11/26/24. Facility equipped with elevators, last service date 5/2/24.

Continued on 809C...
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: OAKMONT GARDENS
FACILITY NUMBER: 496803998
VISIT DATE: 01/14/2025
NARRATIVE
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Continued from 809...

At approximately 11:00am LPA conducted a review of 6 resident records. No deficiencies.

At approximately 12:00pm LPA conducted review of 5 staff records. Five [5] out of five [5] staff (S3, S4, S5, S6, and S7) did not have the required hours of training completed (deficiency cited, see 809D). Three [3] out of five [5] of the reviewed staff files were the files of employees assisting residents with self-administration of medication. LPA and Admin discussed Health and Safety Code (HSC) 1569.69 which covers employees assisting residents with self-administration of medication training requirements. LPA and Admin discussed the medication test referenced in the HSC that is required for all those employees assisting residents with self-administration of medication. Four [4] out of five [5] staff (S3, S4, S5, and S6) did not have 1st Aid/CPR on file (deficiency cited, see 809D)

LPA and Admin reviewed Guardian roster in comparison to current staff roster. Two [2] staff members (S1 and S2) were found to not have fingerprint clearance (deficiency cited, see 809D).

At approximately 3:00pm LPA and Health and Wellness Director (HWD) conducted a spot check of medication and medication records. Medication is centrally stored in a locked room. No deficiencies.


LPA and Administrator discussed facility's Infection Control Plan and Emergency Disaster plan. No new updates.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:
LIC500- Personnel Report
Liability Insurance

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

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

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
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Page: 2 of 6
Document Has Been Signed on 01/14/2025 04:19 PM - It Cannot Be Edited


Created By: Christi Coppo On 01/14/2025 at 03:35 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: OAKMONT GARDENS
FACILITY NUMBER: 496803998

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(a)(13)(B)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: (B) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that S1 and S2 did not have fingerprint clearance on file and were not associated to the facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/15/2025
Plan of Correction
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Facility to submit LIC9098 by plan of correction due date self-certifying that S1 and S2 will not be present at the facility in any capacity until such time that their fingerprint clearance is granted and they are associated to the facility.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 01/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/14/2025 04:19 PM - It Cannot Be Edited


Created By: Christi Coppo On 01/14/2025 at 03:35 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: OAKMONT GARDENS
FACILITY NUMBER: 496803998

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and Admin observation, the licensee did not comply with the section cited above in that disinfectants and cleaning solutions were observed in unlocked cabinet in ancillary Assisted Living Dining room, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/21/2025
Plan of Correction
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Facility immediately removed all disinfectants and cleaning solutions that were observed in unlocked cabinet in ancillary Assisted Living Dining room. Facility to submit LIC9098 self-certifying that the cabinet will either remain locked or that no disinfectants and cleaning solutions will be stored in cabinet, by plan of correction due date.
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that S3, S4, S5, and S6 did not have 1st Aid/CPR on file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/04/2025
Plan of Correction
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Facility to submit current 1st Aid/CPR cards for S3, S4, S5, and S6 by plan of correction due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 01/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2025


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 01/14/2025 04:19 PM - It Cannot Be Edited


Created By: Christi Coppo On 01/14/2025 at 03:35 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: OAKMONT GARDENS
FACILITY NUMBER: 496803998

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that S3, S4, S5, S6, and S7 did not have the required hours of training completed, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/04/2025
Plan of Correction
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Facility to submit training logs for S6 in the amount of no less than 13.5 hours, and for S7 in the amount of 40 hours by plan of correction due date. Facility to submit training logs for S3 in the amount of no less than 5.75 hours, for S4 in the amount of no less than 40 hours, and for S5 in the amount of no less than 8 hours by plan of correction due date. S3, S4, and S5 must have all required medication training hours.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 01/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2025


LIC809 (FAS) - (06/04)
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