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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530137
Report Date: 10/27/2023
Date Signed: 10/27/2023 01:27:28 PM

Document Has Been Signed on 10/27/2023 01:27 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:HILLS OF HAMILTON, THEFACILITY NUMBER:
365530137
ADMINISTRATOR:RAMIREZ, SOPHIAFACILITY TYPE:
740
ADDRESS:10466 HAMILTON STREETTELEPHONE:
(714) 430-7672
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91701
CAPACITY: 6CENSUS: 4DATE:
10/27/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Felita "Fely" Fmu, CaregiverTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at The Hills of Hamilton Residential Care Facility to conduct a Health and Safety Case Management Visit. This Case Management visit is in response to a Special/Unusual Incident Report, (SIR) received by this agency on October 23rd, 2023. LPA met with Caregiver, Fely, introduced self and stated purpose of the visit; which is to gather more information about the incident. LPA was granted entry and signed in. Staff contacted Administrator to notify of LPA's visit. LPA spoke to Administrator and discussed purpose of the visit, the resident and the Physician's Report.
LPA was informed R1 was admitted to the hospital and not present at the time of visit.

During today's visit, LPA was accompanied on a tour of the facility, completed record reviews and staff interviews. At approximately 12:15pm LPA reviewed R1's Physician's Report, (LIC602) and observed that R1 is non-ambulatory, unable to transfer to and from bed and not able to leave the facility unassisted. With both staff and Administrator, LPA discussed the importance of the LIC602, ambulatory status, transfers, the level of care/supervision required for the resident. Additionally, R1's family involvement and communication with the family.

Based on record reviews and staff interviews. A deficiency is being cited to address concerns mentioned above, per Title 22, California Code of Regulations. An exit interview was conducted to discuss plan of correction. A copy of this report was read/reviewed with Licensee; signature acknowledges understanding and receipt of report and attachments.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/27/2023 01:27 PM - It Cannot Be Edited


Created By: Amber Coleman On 10/27/2023 at 01:11 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: HILLS OF HAMILTON, THE
FACILITY NUMBER: 365530137

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/30/2023
Section Cited
CCR
80078(a)

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80078 Responsibility for Providing Care and Supervision
(a) The licensee shall provide care and supervision as necessary to meet the client's needs.
This requirement is not met as evidenced by:
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Administrator agrees to complete a statement of understanding, by way of an LIC9098, complete a plan of communication with R1's family to ensure that the resident has supervision when leaving the facility. Administrator agrees to submit this plan of communication and LIC9098 form to the
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Based on interviews and record reviews, the Administrator failed to ensure the resident had assistance/supervision before leaving the facility on 10/12/23 which posed an immediate Health, Safety and Personal Rights risk to persons in care.
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Community Care Licensing office by 10/30/23.

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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:Nedra Brown
LICENSING EVALUATOR NAME:Amber Coleman
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2023


LIC809 (FAS) - (06/04)
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