216804066-4-7-2023-21-AS-KMOA-CR3QWF-20230420123152

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216804066
Report Date: 04/07/2023
Date Signed: 04/07/2023 03:03:20 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
10/31/2022 and conducted by Evaluator Dominic Tobola

COMPLAINT CONTROL NUMBER: 21-AS-20221031165722

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: 38	DATE:	04/07/2023
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Kevin Hogan, Executive Director		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Staff failed to respond to resident care needs

INVESTIGATION FINDINGS:

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On 4/7/2023, Licensing Program Analyst, (LPA) Tobola arrived unannounced for the purpose of delivering complaint investigation and was greeted by Executive Director, Kevin Hogan (ED). LPA Tobola toured the facility, reviewed resident records, interviewed staff and made observations.

Complaint alleges staff failed to respond to resident care needs. Based on a review of records LPA found that resident (R1) was diagnosed with dementia and was located on the second floor of the facility. R1 required room face to face room checks twice per day based on R1's Care Plan. Complainant stated that facility did not respond to resident calls or provide appropriate care in a timely manner. Facility utilizes a call light and personal pendant for residents to activate; signaling to all staff pagers and medication rooms.
Continued onto LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20221031165722

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: ELEGANCE HAMILTON HILL	FACILITY NUMBER: 216804066
	VISIT DATE: 04/07/2023

NARRATIVE

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Upon a tour of the facility, LPA found a total of 3 staff pagers located on the first floor to be inoperable. Interview with staff (S1) indicated that the pagers had not been operable for approximately 3-4 weeks. LPA and Director tested call light buttons in resident bedrooms on the first and second floors. Staff responded to the call light on the second floor in a timely manner. However, once call lights were tested on the first floor, no response from staff was observed after approximately 13 minutes. LPA and Director found 2 staff (S2 & S3) providing care on the first floor, none of which were properly equipped with staff pagers to respond to call lights appropriately.

Allegation, staff failed to respond to resident care needs is found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

The following deficiencies were cited on LIC9099-D, per Title 22 Regulations, Division 6. Appeal Rights Given.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20221031165722

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: ELEGANCE HAMILTON HILL	FACILITY NUMBER: 216804066
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/07/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/14/2023 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411(a)Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator has contacted Maintenance Services and placed order for new staff pagers, ensuring full operation. Training will be implemented for all staff on resident call light system and Regulation
	8 9 10 11 12 13 14	Based on LPA observation, faciltiy failed to respond to resident care needs due to 2 caregiving staff found to have not been equipped with call pagers. In addtion, 3 out of 3 pagers were found to be inoperable. This poses as a potential health & safety risk to residents in care.	8 9 10 11 12 13 14	87411-Personnel Requirements. Staff signatures submitted to CCLD by POC date 4/14/23. Administrator to develop written plan for device operation checks ensuring compliance. Plan by 4/14/2023.
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	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023

LIC9099 (FAS) - (06/04)

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