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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804066
Report Date: 03/13/2025
Date Signed: 03/13/2025 03:25:48 PM

Document Has Been Signed on 03/13/2025 03:25 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:		LOMELI. LISA MFACILITY TYPE:
740
ADDRESS:1 HAMILTON HILL DRIVETELEPHONE:
(415) 889-8026
CITY:NOVATOSTATE: CAZIP CODE:
94949
CAPACITY: 95CENSUS: 80DATE:
03/13/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Karina Vasquez, Business DirectorTIME VISIT/
INSPECTION COMPLETED:
03:40 PM
NARRATIVE
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At approximately 1:00PM, Licensing Program Analyst (LPA) Loera arrived unannounced to conduct a Case Management - Incident Visit and met with Business Director, Karina Vasquez. The purpose of the visit was to follow up on self reported incident that was submitted to Community Care Licensing (CCL).

CCL received an incident report on 02/21/2025. Report stated that on 02/14/2025, Resident (R1) who is ambulatory with and without a device, eloped from community around 11:00am. Memory Support alarmed doors notified staff that someone exited from Memory Support Unit but when checked it was found out to be a visitor exiting without the code. Med Tech did resident check per protocol and did not see R1. Staff began to search for missing resident. First responders notified community that resident was found safe off premises 0.8 miles away and HSA in response to code found R1 with first responders around 11:10am. R1 was returned to community after EMTs found no need for resident to be transported to the emergency room as R1 was in no need of medical attention and staff member was with R1 awaiting return to community. (Deficiency Cited)

Per R1s physician's report (LIC602) R1 is diagnosed with dementia and is unable to leave facility unassisted.

Based on conversation with Business Director, No one knew how R1 got out. Facility conducted an in-service training for memory staff for elopement the same day (02/14/2025) as the incident happened. Facility conducted an all staff elopement training on 02/19/2025.

See LIC809-D for Deficiency. Exit interview conducted with Business Manager and a copy of this report along with LIC811 (Confidential Names) was provided.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 03/13/2025 03:25 PM - It Cannot Be Edited


Created By: Anthony Loera On 03/13/2025 at 02:25 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: 03/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/13/2025
Section Cited
CCR
87411(a)

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87411(a) Personal Requirements - General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidence by:
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Cleared at time of visit. Facility conducted an in-service training about elopement procedures and has been completed for all memory care staff in the community.
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Based on incident report and interview, facility failed to provide supervision to R1 resulting in an elopement. The absense of supervision is an immediate risk to the Health, Safety and Rights of resident in care.
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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: 03/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2025


LIC809 (FAS) - (06/04)
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