216804066-9-7-2023-21-AS-CFES-CVFVZ7-20230907165215

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216804066
Report Date: 09/07/2023
Date Signed: 09/07/2023 04:52:24 PM

Document Has Been Signed on 09/07/2023 04:52 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, THE		FACILITY NUMBER:	216804066
ADMINISTRATOR:	MUOZ, DENISE		FACILITY TYPE:	740
ADDRESS:	1 HAMILTON HILL DRIVE		TELEPHONE:	(415) 569-7224
CITY:	NOVATO	STATE: CA	ZIP CODE:	94949
CAPACITY: 95		CENSUS: 41	DATE:	09/07/2023
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Executive Director, Jessica Graham		TIME COMPLETED:	05:10 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At approximately 1:15PM, Licensing Program Analysts (LPAs) Felias and Rummonds arrived unannounced to continue a Required 1 Year Visit and met with the front desk receptionist. Executive Director, Jessica Graham arrived during visit at approximately 2:00PM. 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 41 Residents in care. LPAs were also informed there were 48 staff members on site. LPAs reviewed a sample size of 6 resident files. Files were found to be well organized, thorough and contained the required documentation. LPAs also reviewed a sample size of 2 medication records. LPAs also followed up on self-reported incidents that were submitted to Community Care Licensing (CCL). The following incident reports were discussed with Executive Director: Incident Report 1/Incident Report 2: CCL received an incident report on 06/19/2023. The report states that on 06/08/2023, Resident 1 (R1) was being transferred by two staff members. During the transfer, R1's wheelchair became unlocked resulting in R1 being assisted to the ground by staff. R1 was observed to bump their head on the wall but refused to be evaluated by Emergency Personnel. Report stated that R1's Responsible Party was to provide a new wheelchair for R1. Facility contacted R1's physician and responsible party appropriately. On 06/19/2023, CCL received updated incident report for R1. Report states that on 06/9/2023, R1 was being transferred by two staff members. R1's wheelchair became unlocked resulting in R1 being assisted to the ground by staff. Facility contacted R1's physician and responsible party appropriately. Report stated that R1 would use Facility's wheelchair until Responsible Party provided one. LPAs discussed R1 with Executive Director. Per conversation with Executive Director, R1 refused to have their wheelchair replaced. Facility replaced wheelchair the next day with a brand new one when it was observed that the wheelchair was in disrepair. Continued on LIC809C

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

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: 09/07/2023

NARRATIVE

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Continued from LIC809

Incident Report 3: CCL received an incident report on 06/20/2023. The report states that on 06/11/2023, facility staff observed that three medications for Resident 2 (R2) were missing from the pharmacy's monthly cycle fill. Facility staff contacted pharmacy and R2's physician. Report states that 1 of 3 medications was not administered until 06/12/2023, and that 2 of 3 medications were not administered until 06/15/2023. Facility conducted an In-Service training on the following topics: medication cycle preparation, when to contact the pharmacy for refills, and how to properly store and document received medications. Facility contacted R2's physician and responsible party.

LPAs discussed R2 with Executive Director and reviewed their medication records.

Death Report 1: CCL received a death report on 07/03/2023. The report states that on 06/19/2023, Resident 3 (R3) was transported to the hospital for shortness of breath and refused treatment at the hospital. R3 passed away on 06/30/2023 and was not on hospice.

LPAs requested for the death certificate of R3 to be submitted to CCL for review.

incident Report 4: CCL received an incident report on 08/16/2023. The report states that on 08/05/2023, it was observed that an order clarification from Resident 4 (R4) was received by their urologist indicating when an antibiotic was to be started. Facility staff contacted pharmacy and R4's physician for clarification. Report states the order clarification was sent to the pharmacy, was filled, and was administered to R4. R4 received 3 doses of antibiotics. Facility received clarification from R4's urologist and physician stating that there was no active order of antibiotic to be provided. Facility informed urologist and physician of medication error and was informed that R4 should have no adverse effects. R4 was monitored. Facility contacted R4's physician and responsible party. Facility conducted an In-Service Training on the following topic: medication order processing.

LPAs discussed R4 with Executive Director and reviewed their medication records.

LPAs were provided with Facility's In-Service Training documentation.

LPAs were informed that Executive Director is still in their Administrator Certification course. Until this is completed, Denise Munoz, Director of Administration, is the Administrator for the Facility. Executive Director understands that once their certification is completed, their Administrator paperwork needs to be submitted to CCL for a Change of Administrator to occur.
Continued on LIC809C

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/07/2023 04:52 PM - It Cannot Be Edited

Created By: Caitlynn Felias On 09/07/2023 at 03:54 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: 09/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(a)(4)

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on file review and observations made, the Licensee did not comply with the section cited above for 2 of 2 residents. LPAs observed that medications for 2 residents were not administered as required. This poses a potential health and safety risk to residents in care.
	POC Due Date: 09/17/2023
	Plan of Correction
1 2 3 4	Licensee to submit a step by step plan detailing their new procedures for medication audits and in-service trainings for new hires. Plan to be submitted to CCL for review and approval by POC due date of 09/17/2023.

Type B

Section Cited

CCR

87211(a)(1)(D)

87211 Reporting Requirements:(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including...the following:(1)A written report shall be submitted to the licensing agency...within seven days of the occurrence of...(D) Any incident which threatens the welfare, safety or health of any resident... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on file review and observations made, the Licensee did not comply with the section cited above for 2 of 2 residents. LPAs observed that medications for 2 residents were not administered as required. This poses a potential health and safety risk to residents in care.
	POC Due Date: 09/17/2023
	Plan of Correction
1 2 3 4	POC: Licensee to provide training to all Staff reviewing the Regulation: 87211 Reporting Requirements. Inservice Training to include the following information: Date of Training, Training Topics, Job Role, Staff Names and Signatures. Training to be submitted to CCL for review and approval by POC due date of 09/17/2023.

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: 09/07/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

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: 09/07/2023

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Continued from LIC809C

Facility to submit the following documents in order to change Facility Administrator.
Administrator Documents
· LIC 308 (Designation of Facility Responsibility)
· Active and Current Administrator Certificate
· First Aid Certificate
· Administrator Resume
· LIC 500 (Personnel Report)
· LIC 501 (Personnel Record)
· LIC 503 (Health Screening Report - personnel)
· Proof of Negative TB test
· LIC 9182 (Criminal Record Exemption Transfer Request)
· LIC 508 (Criminal Record Statement)
· Copy of Driver's License or Passport that is not expired
· Copy of Board of Directors' Resolution meeting minutes signed (required for all corporations)

LPAs requested the following documents to update facility file:

Designation of Facility Responsibility (LIC 308)
Emergency Disaster Plan (LIC 610D)
Updated Personnel Report (LIC 500)
Register of Clients/Residents (LIC 9020)
Updated Liability Insurance

Facility documents to be submitted to CCL by Saturday, 10/07/2023.

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.

Exit interview conducted. Copy of report, LIC809D, LIC811 (Confidential Names), Plan of Corrections, and Appeal Rights discussed and provided to Executive Director. Signature on form confirms receipt of documents.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

LIC809 (FAS) - (06/04)

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