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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804066
Report Date: 08/21/2023
Date Signed: 08/21/2023 04:09:17 PM

Document Has Been Signed on 08/21/2023 04:09 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:BLUFFS AT HAMILTON HILL, THEFACILITY NUMBER:
216804066
ADMINISTRATOR:MUOZ, DENISEFACILITY TYPE:
740
ADDRESS:1 HAMILTON HILL DRIVETELEPHONE:
(415) 569-7224
CITY:NOVATOSTATE: CAZIP CODE:
94949
CAPACITY: 95CENSUS: 39DATE:
08/21/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Executive Director, Jessica Graham, and Interim Executive Director, Morgan WareTIME COMPLETED:
04:15 PM
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At approximately 9:30AM, Licensing Program Analysts (LPAs) Felias and Rummonds arrived unannounced to conduct a Required 1 Year Visit and met with Executive Director, Jessica Graham. Interim Executive Director, Morgan Ware, arrived approximately at 10:45. Facility is a Residential Care Facility for the Elderly that provides care and assistance for Older Adults in Assisted Living and Memory Care. Facility has an approved fire clearance for 81 Non-Ambulatory Residents, and 14 Bedridden Residents for a total capacity of 95 Residents. Facility has a Hospice Waiver for 10 individuals. Upon arrival, LPAs were informed that there were 39 Residents in care. LPAs were also informed there were 14 staff members on site.

LPAs reviewed a sample size of 6 staff files. Review of files indicated that 4 of 6 staff files did not have proof of a negative TB test. 3 of 6 staff files reviewed did not have proof of a heath screening done. 3 of 6 staff files reviewed did not have proof of current First Aid/CPR certificates. 1 of 6 staff files reviewed also showed that Staff Member 1 (S1) was not fingerprint cleared or associated to the facility per regulation (This Deficiency has been cited, see LIC809D, Regulation 87355(e)). LPAs contacted the Regional Office and confirmed the fingerprint clearance and association status of S1. Regional Office confirmed their fingerprint and association status to the facility. S1 was informed of their status and immediately left the premises.

LPAs were provided documentation regarding the 6 staff files reviewed earlier. Documentation provided showed that Facility has some paperwork on-site regarding staff health screenings, TB tests, and first aid certification. Facility was able to provide documentation for the following areas identified above: 2 staff members missing their TB tests, and 3 staff members missing their health screening reports. LPAs were also provided with staff members who have current first aid/CPR certifications. Deficiencies have been cited for documentation unable to be provided during the time of visit for 2 of 6 staff files reviewed. These staff files are still missing proof of a negative TB test (This Deficiency has been cited, see LIC809D, Regulation 87411(f)).

LPAs unable to complete the Annual Inspection. Annual Continuation Visit to be conducted at a later date.

Continued on LIC809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 08/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/21/2023
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BLUFFS AT HAMILTON HILL, THE
FACILITY NUMBER: 216804066
VISIT DATE: 08/21/2023
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Continued from LIC809

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.

**A Civil Penalty in the amount of $1,000.00 is being issued today, due to a repeat violation of the same regulation regarding background clearance within a 12 month period. (See LIC421IM).**

Exit interview conducted. Copy of report, LIC809D, LIC421IM, LIC811 (Confidential Names), Plan of Corrections, and Appeal Rights discussed and provided to Interim Executive Director. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/21/2023 04:09 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 08/21/2023 at 02:41 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: BLUFFS AT HAMILTON HILL, THE
FACILITY NUMBER: 216804066

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)

87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on Record Review and Observations made, Licensee did not comply with the section cited above and did not ensure that Staff Member 1 (S1) had the proper background clearance needed to work at the facility. This poses an immediate health and safety risk to residents in care.
POC Due Date: 08/22/2023
Plan of Correction
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Licensee to ensure that all individuals subject to a criminal record review receive proper clearance and are associated to facility per Title 22 regulations. Licensee to submit a detailed step by step plan for how they will ensure fingerprint clearance and association is complete for employees prior to them working. Plan to be submitted to Department by POC due date of Tuesday, 08/22/2023.
Type A
Section Cited
CCR
87411(f)
87411 Personnel Requirements – General
(f) All personnel...shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure...


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on Records Review and Observations, the Licensee did not comply with the section cited above. LPAs observed that 2 of 6 staff files reviewed did not have a negative TB test on file. This poses an immediate health and safety risk to residents in care.
POC Due Date: 08/22/2023
Plan of Correction
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Licensee to submit self certification that all staff will have a health screening report and TB test on file as required by Title 22 Regulations. Proof of TB results for identified staff members to be submitted to Department by POC due date of Tuesday, 08/22/2023.
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:Kimberley Mota
LICENSING EVALUATOR NAME:Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:
DATE: 08/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2023


LIC809 (FAS) - (06/04)
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