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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803951
Report Date: 08/04/2022
Date Signed: 08/04/2022 10:47:17 AM


Document Has Been Signed on 08/04/2022 10:47 AM - It Cannot Be Edited

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



FACILITY NAME:ELEGANCE HAMILTON HILLFACILITY NUMBER:
216803951
ADMINISTRATOR:EDWARDS, SUSANFACILITY TYPE:
740
ADDRESS:1 HAMILTON HILL DR.TELEPHONE:
(415) 908-1462
CITY:NOVATOSTATE: CAZIP CODE:
94949
CAPACITY:95CENSUS: 37DATE:
08/04/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Susan Edwards - Executive DirectorTIME COMPLETED:
10:46 PM
NARRATIVE
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Licensing Program Analyst (LPA) Fernandes-Goes arrived unannounced to conduct a case management visit regarding incident report submitted to Community Care Licensing (CCL) for resident R1 which occurred on 7/7/2022. LPA met with Susan Edwards - Executive Director.

Per facility incident report, interviews, and documentation reviewed; Department learned that resident R1 has a doctor's orders - dated 5/18/2022 - for 3x per day of Pregabalin 25 mg caps, however; facility administered 2x day from 5/27/22 until 7/16/2022. In addition during facility auditing of medication, facilitty learned that medication Diltiazem was ordered once daily and administered 2x daily since 6/1/2022 until 7//6/2022. Resident R1's physician's report dated 5/18/2022 and move in date was 5/27/2022. Resident has a diagnosis of dementia and can't store or administer its own medication. Facility staff entered the wrong order for both medications above. This event was noticed by family member. Facility checked doctor's orders and learned that medications were been dispensed in error. (see confidential name list, LIC 809-D)

Since incident per facility staff, facility has conducted medication technicians training on medications; facility is conducting on -going audits; and doctor for resident R1 was contacted and an updated list of medications for resident is on file. Facility provided Department with copy of documents for resident R1. In addition, facility will be submitting proof of medication technicians training, proof of 100 % medication audit, and a facility plan on how med techs will ensure that medications are being dispensed according with doctor's orders by POC date of 8/5/2022.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided. Appeal of Rights Given.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2022
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 08/04/2022 10:47 AM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/05/2022
Section Cited

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87465(a)(5) Incidental Medical and Dental Care Services. This requirement isn't met as evidenced by:Based on incident report, interviews, and docs reviewed facility didn't comply
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w/section above as facility administer Pregabalin and Diltiazem meds for resident R1 different from what doctor had order which poses an immediately Health, Safety, and Personal rights risk for residents in care. (see copies)
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accoriding with doctor's orders, proof of medication technicians training, and proof of 100 % medication audit by POC date of 8/5/22.

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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: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2022
LIC809 (FAS) - (06/04)
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