<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803951
Report Date: 04/19/2022
Date Signed: 05/04/2022 01:44:13 PM


Document Has Been Signed on 05/04/2022 01:44 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 04/21/2022 09:36 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
"Amended" This report has been amended to appropriate date and temperature for hot water.
Licensing Program Analyst (LPA) Fernandes-Goes conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with Executive Director Susan Edwards. There were 31 residents with 6 under hospice and 17 memory care at facility. Facility has activities planned for residents during the day.

LPA arrived at the facility and had her temperature checked and logged into a log. During facility tour on 4/19/2022 with administrator; facility was found to be clean, good repair, and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 10/2021 at the time of the visit. Fire sprinklers are inspected annually, and inspection records are current with the last inspection being conducted on 11/29/2021. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Facility has residents' with a special diet; kitchen has a binder with a form for each resident with their special needs, and when food is served to these residents, they are placed in a plate with their names on. Facility hot water temperature in clients' bathroom faucets measured between 110.8 degrees F and 118.5 degrees F in 9 out of 9 faucets within Title 22 acceptable regulations of 105 to 120 degrees F. Toxins are stored in a locked housekeeper storage. Dangerous items were stored inaccessible to develop disabled residents. There was a supply of cleaners, hygiene products and paper products available for residents. The bathroom designated for residents at the facility were supplied with individual paper towels; hand soap dispenser was available. Sample resident’s bedrooms have lighting & appropriate furnishings. Disaster drills are being conducted quarterly with records for last fire drill on 3/31/2022.

Continued LIC 809-C
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ELEGANCE HAMILTON HILL
FACILITY NUMBER: 216803951
VISIT DATE: 04/19/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Infection Control:
Facility has submitted a mitigation program plan that has been approved. Some posters have been placed at entrance and bathrooms. Facility has hand sanitizer available; visitors and staff before coming into work have temperature checked. Facility has PPE supply stored in the facility 2nd floor storage closed. Facility has hired and admitted new staff and residents since COVID-19. Resident’s medications are stored and locked in medication room. Facility has a 30-day supply of medication for clients. Residents are not wearing masks inside the facility, however; staff stated that they are able to wear masks when going on outings. All staff had masks on during this visit. In addition, facility has a designated area for visitors which are being allowed. Residents have also available virtual and telephone calls when contacting with family members and others. Per facility staff all PPE training required and N-95 fit testing for staff are on available on file for Department to review.

In addition, facility is working towards change of administrator. At this time Department is still waiting for the following documentation: LIC 200 ; LIC 308, Copy of Board of Director's Resolution meeting minutes signed, Copy of Diploma Certificate for new administrator.

There were no deficiencies cited at this time.

Department is requesting facility to submit the following update documents by 4/27/2022:

LIC 308 Designated
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 610E-S Supplemental Emergency Disaster Plan for RCFE
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Certificate of Liability Insurance
Copy of Administrator Certificate
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3