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Complaint Investigation

Novato Healthcare Center

Inspection Date: August 20, 2025
Total Violations 1
Facility ID 555844
Location NOVATO, CA
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Inspection Findings

F-Tag F0609

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Based on interview and record review, the facility failed to ensure an allegation of abuse was reported within the required timeframe for two of two sampled residents (Resident 1 and Resident 2) when no documentation was received by the Department of Public Health (the Department) until four days after the alleged abuse occurred.This failure of timely reporting had the potential to cause a delayed response by enforcement agencies to ensure resident safety.Findings:A review of a facility document titled Investigation Summary of Resident 1 and Resident 2 dated 7/17/25 and received by the Department on 7/17/25, indicated Resident 1 made verbal threats towards Resident 2 on 7/13/25.During an interview on 8/19/25 at 12:12 p.m., the Administrator (ADM) stated it was the facility's policy to report an allegation of abuse to the Department within two hours. The ADM confirmed the facility sent the five-day follow up report to the Department on 7/17/25 for an incident of alleged abuse on 7/13/25.During an interview on 8/19/25 at 12:30 p.m., Licensed Nurse A (LN A) stated he faxed a State of California Report of Suspected Dependent/Elder Abuse (referred to as the SOC 341) to the Department on 7/13/25 but could not recall the time. LN A stated

he did not get confirmation the fax was sent to the Department. LN A stated the facility policy was to report allegations of abuse within two hours. During an interview on 8/19/25 at 12:58 p.m., Licensed Nurse B stated he witnessed an incident of verbal abuse between Resident 1 and Resident 2 on 7/13/25 at 4:30 p.m. LN B stated facility protocol was to notify the Department within two hours of any incident of alleged abuse. LN B stated he called the Department at 7:18 p.m. and left a voice message. A record review of the Department's voice mail log dated 7/11/25 through 7/14/25 indicated no voicemails were received from any staff from the facility regarding an allegation of abuse between Resident 1 and Resident 2.During an

interview on 8/20/25 at 12:50 p.m., the ADM stated the expectation was for staff to respond immediately to any resident-to-resident altercations and report to the Department within two hours. The ADM verified there was not a fax confirmation of an SOC 341 sent to the Department on 7/13/25. The ADM confirmed there was no proof that a phone call was made to the Department to report the incident on 7/13/25. The ADM stated if a phone call had been made on 7/13/25 at 7:18 p.m. for an incident which occurred on 7/13/25 at 4:30 p.m., it would not have been within the two-hour reporting timeframe.A record review of the facility's policy titled, Abuse Prevention and Management and dated 5/30/24 indicated, The administrator or designated representative will.send a written SOC 341 report to. CDPH Licensing and Certification within two hours.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

📋 Inspection Summary

NOVATO HEALTHCARE CENTER in NOVATO, CA inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in NOVATO, CA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from NOVATO HEALTHCARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.
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