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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804066
Report Date: 12/29/2022
Date Signed: 12/29/2022 01:07:56 PM


Document Has Been Signed on 12/29/2022 01:07 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:
216804066
ADMINISTRATOR:EDWARDS, SUSANFACILITY TYPE:
740
ADDRESS:1 HAMILTON HILL DRIVETELEPHONE:
(415) 569-7224
CITY:NOVATOSTATE: CAZIP CODE:
94949
CAPACITY:95CENSUS: 39DATE:
12/29/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Administrator, Kevin J. HoganTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Elegance Hamilton Hill for the purpose of conducting a Post Licensing inspection. LPA was met at the door by, Administrator, Kevin J. Hogan, and was granted access into the facility.

LPA and Administrator toured the facility. Facility is clean, in good repair and at a comfortable temperature. A sample of rooms hot water temperature were tested and measured at 115 degrees in 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. 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. There is an outdoor space for activities. Fire Extinguishers were found to be last charged on October 2022 at the time of the inspection. First aid kit was inspected and found to be appropriate during the inspection. First aid kit has been placed in few different areas of the facility. 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 inspection. Menus for dining are posted on the board and place on dining table. 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 are inaccessible to residents.

LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has PPE. Staff have had all PPE training required and have been N95 Fit tested on December 2022. (Report continued on LIC 809C)
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/29/2022
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: 12/29/2022
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LPA requested the following documents to be sent to CCL:

LIC 500- Personnel Report
LIC 308- Designation of Responsibility
LIC 309- Administrative Organization
LIC 400- Affidavit regarding Client Cash Resources
LIC 610D-Emergency Disaster Plan
Fire Alarm System test
Updated facility sketch
Surety Bond
Most up-to-date Liability insurance
Control of Property
Register of Residents

No deficiencies were observed or cited during the Post Licensing Inspection. Exit interview was conducted and a copy of this report was given to the Administrator.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022
LIC809 (FAS) - (06/04)
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