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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803951
Report Date: 09/12/2022
Date Signed: 09/12/2022 07:04:15 PM


Document Has Been Signed on 09/12/2022 07:04 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
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: 42DATE:
09/12/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Susan Edwards - Executive DirectorsTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Fernandes-Goes conducted an unannounced case management and met with Susan Edwards - Executive Director and Katelyn Ledesma - Resident Health & Wellness Director/ Assistant Executive Director. The purpose of the case management visit was to obtain additional information regarding SOC 341 Suspect Abuse that is believed to have occurred on September 5, 2022 for resident R1 - facility reported to the Department as soon as facility learned.

LPA interviewed Executive Director, Ass. Executive Director, caregivers, & resident R1, and acquired documentation. Per facility ED, pictures have been taken of bruises for resident R1, suspect abuser is believed to be an agency staff and individual is no longer working at facility. Facility will be contacting police; family member has been able to speak with resident and gather some information.

In addition, during file review and interview LPA learned that staff S1 has worked at least 2x - one of the days was 9/5/2022 at facility and hasn't been associated to facility. It is believed that S1 is fingerprint cleared. (see LIC 811 Confidential name list, LIC 809-D, Civil Penalties)

Immediate Civil Penalties are being assessed in the amount of $200 due to staff not being associated to the facility.

*****Total Civil Penalties issued today in the amount of $200.00.

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: 09/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2022
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 09/12/2022 07:04 PM - 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: 09/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/13/2022
Section Cited

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87355 Criminal Record Clearance.This requirement isnt met as evidenced by: Based on records reviewed facility didn't comply w/section above on 1 out of 1 agency staff association before providing care to residents
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which poses an immediate health, safety,& personal rights risk to residents in care.CCLD interview staff provided by facility & learned that staff S1 isnt associated to facility.Staff S2 worked at least 2 days w/last day 9/5/22.
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this regulation and that all staff and volunteers at facility are and will be fingerprint cleared and associated to the facility by 9/13/22. (see Civil Penalty)

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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: 09/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2022
LIC809 (FAS) - (06/04)
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