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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804066
Report Date: 10/03/2024
Date Signed: 10/03/2024 03:19:01 PM

Document Has Been Signed on 10/03/2024 03:19 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:BLUFFS AT HAMILTON HILL, THEFACILITY NUMBER:
216804066
ADMINISTRATOR/
DIRECTOR:		MUOZ, DENISEFACILITY TYPE:
740
ADDRESS:1 HAMILTON HILL DRIVETELEPHONE:
(415) 889-8026
CITY:NOVATOSTATE: CAZIP CODE:
94949
CAPACITY: 95CENSUS: 69DATE:
10/03/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Business Manager, Karina VasquezTIME VISIT/
INSPECTION COMPLETED:
03:40 PM
NARRATIVE
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10/03/2024 at approximately 9:20am, Licensing Program Analysts (LPA) Loera arrived unannounced to continue an Annual Required inspection that was initiated on 09/04/2024, and was greeted by Business Manager, Karina Vasquez.

At approximately 10:15am, LPA and Business Manager toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. Refrigerated and freezer food was found to be stored in facilities kitchen walk-ins being labeled and dated.

Facility has 4 floors with the first and second floor being designed for Memory Care and floor three and four being designed for Assisted Living. Facility has many common areas including offices, a gym, a salon and activity room. LPA observed an activities calendar for residents to participate. Water temperature in sinks accessible to residents in care were measured within the range of 113.1 and 114.9 which is within 105 to 120 degrees F. Fire extinguishers were last inspected September, 2024. Smoke/Carbon Monoxide detectors are hardwired and located throughout the facility. Medications were found to be centrally stored. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record.

At approximately 11:20 am, LPA conducted review of 8 staff records/training. Upon a review of staff records, LPA found all staff to have required annual and initial training as well as current 1st Aid & CPR certification on file.

At approximately 12:45 am, LPA conducted a review of 7 resident records. All records had the required documentation.

continued on LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2024
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: BLUFFS AT HAMILTON HILL, THE
FACILITY NUMBER: 216804066
VISIT DATE: 10/03/2024
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During inspection LPA followed up on elopement that was self reported to community care licensing (CCL) on 08/16/2024 stating that on 08/11/2024, Resdient ! (R1) had eloped from the community around 7:05pm. Report states Memory Support alarmed doors notified staff that a resident had eloped from Memory Support Unit. Report states staff did a head count and began searching for missing resident and was found around 7:30pm walking outside of community grounds in a nearby neighborhood. Report states R1 was returned back to the community and was put under one on one supervision. (Deficiency Cited)

See LIC809-D for Deficiency. 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
LIC308- Designation of Responsibility
Emergency Disaster Plan (review)
Infection Control Plan (review)

Exit interview conducted with Business Manager and a copy of this report was provided.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/03/2024 03:19 PM - It Cannot Be Edited


Created By: Anthony Loera On 10/03/2024 at 01:58 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: 10/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(b)(2)
87705 Care of Persons with Dementia: (b) In addition to the requirements as specified in Section 87208... plan of operation shall address... residents with dementia, including: (2) Safety measures to address behaviors such as wandering...
This requirement is not met as evidenced by:


Deficient Practice Statement
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Based on document reviewed, the Licensee did not comply with the section cited above. Resident 1 (R1) eloped from facility and was found walking outside of community grounds in a nearby neighborhood . R1’s Physician Report states they have dementia. This poses an immediate health and safety risk to residents in care.
POC Due Date: 10/04/2024
Plan of Correction
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Licensee to submit proof of scheduled training with all care staff regarding Elopement Procedures by POC due date of 10/04/2024.
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:Kimberley Mota
LICENSING EVALUATOR NAME:Anthony Loera
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2024


LIC809 (FAS) - (06/04)
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