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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216804066
Report Date: 08/26/2025
Date Signed: 08/26/2025 02:46:35 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/14/2025 and conducted by Evaluator Anthony Loera
COMPLAINT CONTROL NUMBER: 21-AS-20250714113825
FACILITY NAME:BLUFFS AT HAMILTON HILL, THEFACILITY NUMBER:
216804066
ADMINISTRATOR:LOMELI. LISA MFACILITY TYPE:
740
ADDRESS:1 HAMILTON HILL DRIVETELEPHONE:
(415) 889-8026
CITY:NOVATOSTATE: CAZIP CODE:
94949
CAPACITY:95CENSUS: 85DATE:
08/26/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Karina Vasquez, Business ManagerTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Due to lack of supervision, resident has had multiple falls
INVESTIGATION FINDINGS:
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On 08/26/2025, Licensing Program Analyst (LPA) Loera conducted an unannounced visit for the purpose of delivering complaint findings regarding the above allegation. LPA arrived and met with Business Manager, Karina Vasquez. During the investigation, LPA conducted interviews, reviewed documents and made observations.

Compliant alleges, Due to lack of supervision, resident has had multiple falls.

Based upon review of resident’s (R1) Needs and Service Plan dated (02/03/2025), R1 is to use a walker/cane when ambulating, needs total assistance for ambulation, and walks independently with staff assisting R1 to meals and activities. R1 is encouraged to use their cane, per R1s Needs and Service Plan. Record reviews show R1 has had a total of 8 falls since the beginning of 2025; 01/09/2025, 04/03/2025, 06/18/2025, two on 07/01/2025, 07/11/2025, 07/12/2025, and 07/25/2025.

continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 21-AS-20250714113825
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/26/2025
NARRATIVE
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Record review shows R1s Needs and Service Plan was updated on 06/09/2025 with the goal for R1 to avoid injury from falls by assisting R1 with appropriate shoes when ambulating, verbally remind R1 to ask for assistance with transfers, escort resident to meals and activities, report any changes in condition to physician, staff check in routinely 4 times per shift, remind R1 to use walker as needed (keep within reach), and upon status checks staff are to ask R1 if they need to use the restroom and standby assist if R1 needs to use to toilet. R1s Needs and Service plan was updated after R1 had a fall on 06/18/2025; for nursing staff to ensure R1 has on proper footwear. R1 needs and service plan were updated after R1 had a fall on 07/12/2025 and 07/25/2025 and R1 was placed on hospice on 07/26/2025. Document review of facilities narrative charting notes for R1 reveal the falls happened in their bedroom and/or bathroom. Also review of narrative charting notes show staff documenting R1s falls, change of conditions, check-ins, and reminding R1 to use their cane/walker.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2