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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216804066
Report Date: 12/11/2025
Date Signed: 12/11/2025 04:38:45 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
11/19/2025 and conducted by Evaluator Anthony Loera
COMPLAINT CONTROL NUMBER: 21-AS-20251119091655
FACILITY NAME:BLUFFS AT HAMILTON HILL, THEFACILITY NUMBER:
216804066
ADMINISTRATOR:ACUMABIG. JOSEFACILITY TYPE:
740
ADDRESS:1 HAMILTON HILL DRIVETELEPHONE:
(415) 889-8026
CITY:NOVATOSTATE: CAZIP CODE:
94949
CAPACITY:95CENSUS: 82DATE:
12/11/2025
UNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH: Buisness Manager, Karina VasquezTIME COMPLETED:
04:55 PM
ALLEGATION(S):
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Staff are mismanaging resident's medication
Staff did not follow reporting requirements
INVESTIGATION FINDINGS:
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On 12/11/2025, Licensing Program Analyst (LPA) Loera conducted an unannounced visit for the purpose of delivering complaint findings regarding the above allegations. LPA arrived and met with Buisness Manager, Karina Vasquez. During the investigation, LPA conducted interviews, reviewed documents and made observations.

Compliant alleges, Staff are mismanaging resident's medication and staff did not follow reporting requirements.

During the course of the investigation, document review of residents (R1) MARs records for October 2025 show on October 16th, 2025, at 6:00am R1 did not receive their Morphine Sulf 20mg/ML solution due to no NOC med tech on shift to administer. On November 22nd, 2025, at 8:00am R1 did not receive their routine Morphine 20mg/ml due to no med tech on shift and staff noted “resident is in pain”.

continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2025
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-20251119091655
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: 12/11/2025
NARRATIVE
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Community Care Licensing (CCL) received a Special Incident Report (SIR) on 12/01/2025 regarding R1 missing their scheduled Morphine Sulfate 2.5mg dose. The SIR states the date it occurred on was 11/24/2025, but in the description of the incident it states, “It is noted that on Friday, November 12th, the resident’s scheduled Morphine Sulfate 2.5mg PO does was missed”. It is unclear what date the medication was exactly missed on as November 24th was a Monday and November 12th was a Wednesday. The dates given in the SIR are inaccurate. On October 20th, 2025, it is unclear if R1 received their morphine dose at 8:00am as staff notes state “short staff was passing meds upstairs”. Documentation for November 1st, 2025, at 8:00am, 8:30am, and 12:00pm, it is unclear if R1 received their routine morphine and Refresh Tears Ophth 0.5% drops as staff notes state “short staff”. It should be noted per R1s medication list, R1 is to receive morphine every four hours for pain management. For the dates of October 16th and November 22nd where documentation states R1 missed their medication, CCL did not receive a Special Incident Report (SIR).

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: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20251119091655
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: 12/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/12/2025
Section Cited
CCR
87465(a)
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Incidental Medical and Dental Care 87465(a)(4) The licensee shall assist residents with self-administered medications as needed.

This requirement not met by licensee as evidenced by:
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Licensee to submit plan on how facility will ensure residents receive their prescription mediciation on time to CCL on POC due date 12/12/2025.
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Based on document review of MAR, R1 was not administered their prescription medication on October 16th and November 22nd which poses an immediate health, safety or personal rights risk to persons in care.
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Type B
12/29/2025
Section Cited
CCR
87211(a)(1)
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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence.....
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Facility to conduct training for all staff on reporting requirements and to send proof of completed training to CCL by POC due date 12/29/2025.
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This requirement not met by licensee as evidenced by: Based on document review, facility did not send an incident report to CCL for missed medication for R1 on October 16th and November 22nd, 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: 12/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2025
LIC9099 (FAS) - (06/04)
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