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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216804066
Report Date: 09/03/2025
Date Signed: 09/03/2025 03:43:23 PM

Substantiated


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
07/07/2025 and conducted by Evaluator Anthony Loera
COMPLAINT CONTROL NUMBER: 21-AS-20250707082501
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:
09/03/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Karina Vasquez, Business ManagerTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff do not ensure resident's incontinence needs are being met
Staff do not ensure that resident has clean bedding
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Loera arrived unannounced and met with Karina Vasquez, Business Manager and Sean Bannister, Memory Care Director to deliver findings of a complaint investigation. During the course of this investigation, documents were reviewed, observations made, and interviews conducted.

Complaint alleges staff do not ensure resident's incontinence needs are being met and staff do not ensure that resident has clean bedding.

Allegation, staff do not ensure resident’s incontinence needs are being met. During the investigation, documentation, statements were reviewed, interviews conducted, and observations made. Review of residents (R1) Needs and Service Plan dated 01/21/2025 show R1 has incontinence episodes, wears briefs, needs total assistance with help on the toilet, and assistance with brief changes. R1s care notes show R1 spends most of their day with their spouse on the assisted living side of the facility.

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

DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
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 3
Control Number 21-AS-20250707082501
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: 09/03/2025
NARRATIVE
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Two out of four staff interviews conducted revealed that when R1 is with their spouse in assisted living and R1 has an incontinence episode, assisted living staff will call memory care staff and tell them they need to assist R1 with incontinence care. Per R1s Needs and Service plan under care notes, assisted living staff are to provide care during the day as needed to R1. Under Bladder Incontinence in R1s Needs and Service Plan, states resident will receive assistance with incontinence care as needed and staff will provide physical assistance to changed soiled brief and clothing. During the investigation LPA was provided with additional evidence that R1 pressed their pendant button for assistance around midnight on 08/24/2025 with no answer. Document review of R1s alarm response report shows R1 called for assistance at 11:40PM on 08/24/2025 and didn’t receive assistance until 12:28AM on 08/25/2025, a total of 47 minutes.

Allegation, staff do not ensure that resident has clean bedding, based on interviews that were conducted with facility staff and outside parties, and records reviewed, it was determined R1s previous mattress was found to be saturated in urine. Interviews conducted with outside party revealed they have observed R1s mattress to be saturated in urine multiple times. Interviews conducted with 2 of 5 staff revealed R1s mattress was saturated in urine along with a urine smell before getting discarded. Record review show R1 received a new mattress on 07/07/2025.

Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Division 6, Chapter1 is being cited on the attached LIC 9099D. Appeal rights given.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20250707082501
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/05/2025
Section Cited
HSC
1569.269(a)(6)
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§1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (6) To care, supervision, and services that meet their individual needs...
This requirement is not met by licensee as evidence by record review and interviews......
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Facility shall submit plan to CCL to conduct training for all direct care staff on care and supervision by plan of correction due date 09/05/2025. Facility to submit proof of completed training to CCL by 09/15/25.
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conducted, the licensee did not ensure R1 received assistance from staff on duty and/or receive assistance in a timely manner. This poses an immediate Health, Safety or Personal Rights risk to persons in care.
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Type B
09/03/2025
Section Cited
CCR
87625(b)(3)
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87625 Managed Incontinence (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontience. This......
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Facility provided proof to LPA of new mattress ordered on 07/07/2025. POC cleared at time of visit.
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requirement is not met by licensee as evidence by record review and interviews conducted, the licensee did not ensure R1 had clean bedding as R1s mattress was saturated in urine. This poses a potential health, safety or personal rights risk to persons 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.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
LIC9099 (FAS) - (06/04)
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