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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216804066
Report Date: 11/18/2025
Date Signed: 11/18/2025 03:53:31 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
10/13/2025 and conducted by Evaluator Anthony Loera
COMPLAINT CONTROL NUMBER: 21-AS-20251013154933
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: 82DATE:
11/18/2025
UNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Jose Acumabig, Executive DirectorTIME COMPLETED:
03:55 PM
ALLEGATION(S):
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Staff is not following the personnel requirements
INVESTIGATION FINDINGS:
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On 11/18/2025, Licensing Program Analyst (LPA) Loera conducted an unannounced visit for the purpose of delivering complaint findings. LPA arrived and met with Executive Director, Jose Acumabig. During the course of the investigation, LPA reviewed records, conducted interviews, and made observations.

Complaint alleges, staff is not following the personal requirements. Reporting Party (RP) states on the night of 10/10/2025, the facilities NOC shift was understaffed as three caregivers were on shift for all residents in assisted living and memory care. Document review of facilities scheduled shifts vs. actual hours worked show on the night of 10/10/2025, four staff were scheduled to work 10:30pm – 6:30am, which consisted of three caregivers and one medication technician. Three caregivers were on shift as the medication technician did not show up for their scheduled shift. Two additional care staff, who were not scheduled to work, clocked in from approximately 3:30am to 7:00am. The remaining caregivers that were on shift do not have training to dispense medication. If a resident needed medication during the hours 10:30pm through 6:30am, none of the staff on shift have training to properly dispense medication.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2025
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-20251013154933
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: 11/18/2025
NARRATIVE
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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: 11/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20251013154933
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: 11/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/09/2025
Section Cited
CCR
87411(a)
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87411(a) Personnel 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 is not met as evidenced by:
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Facility to submit self-certification to CCL stating they understand regulation 87411(a) and submit an updated NOC shift schedule to ensure staff on duty have medication training by POC due date 12/09/2025.
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Based on record review, the facility did not ensure staff on duty had training to dispense medication and/or had a med tech on duty which poses an potential health and safety risk to residents 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: 11/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3