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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216804066
Report Date: 09/03/2024
Date Signed: 09/10/2024 12:40:46 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/11/2024 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20240711152524
FACILITY NAME:BLUFFS AT HAMILTON HILL, THEFACILITY NUMBER:
216804066
ADMINISTRATOR:MUOZ, DENISEFACILITY TYPE:
740
ADDRESS:1 HAMILTON HILL DRIVETELEPHONE:
(415) 889-8026
CITY:NOVATOSTATE: CAZIP CODE:
94949
CAPACITY:95CENSUS: 70DATE:
09/03/2024
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Stephanie JuddTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Facility failed to report incident(s) as required per regulation
INVESTIGATION FINDINGS:
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Licensing Program Analyst Leibert arrived unannounced to deliver findings on this complaint. Complainant alleges R1 fell numerous times while in care and was sent out to emergency care on 4/22/2024 and that Responsible Person (RP) was not notified. The following determinations are based on documents reviewed and statements taken: Two incident report were obtained, dated 5/7 and 5/20/2024 indicating R1 fell and that the RP was notified; An E-mail chain was obtained, dated 5/14 and 5/17, 2024, between the RP and the prior Executive Director (ED); The E-mail chain documents the claim that R1 went out for emergency medical care on 4/22/204 and that the staff did not notify the Responsible Person; The prior ED apologized to the RP for the situation and indicated that additional training was given to the staff as a result. Based upon the documents reviewed, the preponderance of evidence standard has been met. Therefore, the complaint is SUBSTANTIATED. The following deficiencies were observed (see LIC 9099D) 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. Report left.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 21-AS-20240711152524
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: BLUFFS AT HAMILTON HILL, THE
FACILITY NUMBER: 216804066
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/12/2024
Section Cited
CCR
87211(a)
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87211(a) A written report shall be submitted to the Licensing agency and to the person responsible for the resident within 7 days of the occurrence......Based upon documents reviewed, this requirement has not been met as evidenced by: R1 was transported for
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Administration shall provide refresher training to staff on the requirements of 87211 and will provide proof of training to CCL by POC date in order to clear the deficiency.
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medical emergency on 4/22/24 and the Responsible Person was not notified by the facility. This posed an immediate risk to the personal rights of R1
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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: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024
LIC9099 (FAS) - (06/04)
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