216804066-9-13-2022-21-AS-CFGS-CJ8MUB-20220913095453

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216804066
Report Date: 09/12/2022
Date Signed: 09/13/2022 09:55:00 AM

Document Has Been Signed on 09/13/2022 09:55 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 HILL		FACILITY NUMBER:	216804066
ADMINISTRATOR:	EDWARDS, SUSAN		FACILITY TYPE:	740
ADDRESS:	1 HAMILTON HILL DRIVE		TELEPHONE:	(415) 569-7224
CITY:	NOVATO	STATE: CA	ZIP CODE:	94949
CAPACITY:	95	CENSUS: 42	DATE:	09/12/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	04:00 PM
MET WITH:	Susan Edwards - Executive Director		TIME COMPLETED:	07:05 PM

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	Licensing Program Analyst (LPA) Fernandes-Goes conducted a pre-licensing inspection and met with Executive Director Susan Edwards & Katelyn Ledesma Assistant Executive Director. Fire clearance has been approved for 95 Non-ambulatory and 14 bedridden residents by the Marin County Fire Department. In addition, facility has a hospice waiver. There were 42 residents with 5 under hospice. LPA will conduct a component III orientation with Executive Director Susan Edwards & Katelyn Ledesma Assistant Executive Director LPA toured facility and observed: Facility is four floors, in good repair and at a comfortable temperature. Hot water temperature checked between 113.8- and 118.2-degrees F in 7 out of 7 resident's faucets as required by Title 22 Regulations. The facility has a phone line designated for residents' use. Personnel and residents' records are stored at the facility office. Facility plans on having awake staff. The building includes kitchen, dining area, activities area, bar and lounge, lobby, beauty salon, bistro, discovery room/visitation room, laundry room, office rooms, medication room, Memory Support and Assisted Living resident's bedrooms, and terrace. Facility plans on having several different activities available for residents as desired and has an activity calendar posted. There is outdoor space for activities. Menus for dining are posted on the board and place on dining table. 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 enough 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 it. Toxins will be locked in housekeeper room on first floor. Facility also has community restrooms downstairs. Postings noted to be current and in compliance with guidelines. Locked cabinets for sharps and daily used toxins. First aid kit has been placed in few different areas of the facility. (continued LIC 809-C)

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 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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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: 216804066
	VISIT DATE: 09/12/2022

NARRATIVE

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Infection Control:
Facility has submitted Infection Program Plan and Emergency Monkeypox Infection Plan. 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 2^nd floor storage closed. 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 available on file for Department to review.

Pre-Licensing is complete, and facility will be submitting self certification by 9/13/2022 in order for facility to be ready for licensure.

There were no deficiencies cited at this time.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 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

LIC809 (FAS) - (06/04)

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