216804066-8-15-2023-21-AS-CFES-CUQVE2-20230815162137

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216804066
Report Date: 08/15/2023
Date Signed: 08/15/2023 04:21:45 PM

Document Has Been Signed on 08/15/2023 04:21 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:	BLUFFS AT HAMILTON HILL, THE		FACILITY NUMBER:	216804066
ADMINISTRATOR:	MUOZ, DENISE		FACILITY TYPE:	740
ADDRESS:	1 HAMILTON HILL DRIVE		TELEPHONE:	(415) 569-7224
CITY:	NOVATO	STATE: CA	ZIP CODE:	94949
CAPACITY:	95	CENSUS: 37	DATE:	08/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Business Manager, Karina Vasquez		TIME COMPLETED:	04:30 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	At approximately 9:30AM, Licensing Program Analysts (LPAs) Felias and Rummonds arrived unannounced to conduct a Required 1 Year Visit and met Business Office Manager, Karina Vasquez and Memory Care Director, Nate Howland. Executive Director in Training, Christine Mancuso, arrived at approximately 11:45AM. Facility is a Residential Care Facility for the Elderly that provides care and assistance for Older Adults in Assisted Living and Memory Care. Facility has an approved fire clearance for 81 Non-Ambulatory Residents, and 14 Bedridden Residents for a total capacity of 95 Residents. Facility has a Hospice Waiver for 10 individuals. Upon arrival, LPAs were informed that there were 20 Residents in Memory Care and 17 Residents in Assisted Living for a total of 37 Residents. LPAs were also informed there were 16 staff members on site. At approximately 9:45AM, LPAs reviewed the staff roster with Memory Care Director. During review, LPAs discovered that Staff Member 1 (S1), Staff Member 2 (S2) and Staff Member 3 (S3) were not fingerprint cleared or associated to the facility per regulation (This Deficiency has been cited, See LIC809D, Regulation 87355(e)).LPAs also discovered that 2 staff members, Staff Member 4 (S4) and Staff Member 5 (S5) were fingerprint cleared, but not associated to the facility as required. LPAs contacted the Regional Office and confirmed the fingerprint clearance and association statuses of all 5 staff members to the facility. S1, S2, and S3 were informed of their status and they immediately left the premises. Facility sent the association paperwork for S4 and S5 to the Regional Office today, 08/15/2023. LPA confirmed with the Regional Office that the paperwork had been received. Administrator understands that S1, S2, and S3 cannot be on the premises of the facility until they have been properly fingerprint cleared and associated to the facility as required. Executive Director in Training understands that a Civil Penalty is not being issued today for S4 and S5 because their association paperwork has been received by the Regional Office to be processed. At approximately 10:50AM, LPAs conducted a walk through with Executive Director in Training and Maintenance Director, Jose Garcia. LPAs observed the following: Facility is comprised of 4 floors with two floors being designated for Memory Care, and two floors designated for Assisted Living. The facility has multiple common areas, activity spaces, and offices. Continued on LIC809C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023

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

LIC809 (FAS) - (06/04)

Page: 1 of 5

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: BLUFFS AT HAMILTON HILL, THE	FACILITY NUMBER: 216804066
	VISIT DATE: 08/15/2023

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
26
27
28
29
30
31
32

Continued from LIC809

Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins were observed to be stored inaccessible to Residents. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for Residents. Mattress pads were in place or available for Resident use. A sample size of 12 sinks were tested. LPAs found that hot water temperatures were within Title 22 regulations of 105 to 120 degrees Fahrenheit.

Facility's fire extinguishers were last inspected October 2022. Facility has a hard wired fire alarm and sprinkler system that is directly connected to the local Fire Department. Smoke detectors and carbon monoxide detectors were last tested in May 2023.

LPAs also discussed the recent change in management for the facility. At this time, a new Executive Director has been hired, Jessica Gram. Until Jessica starts their employment, Interim Executive Director, Morgan Ware, is available in the event of an emergency or resident incident. Per conversation with Executive Director in Training, Facility has ensured that all staff know to contact Jessica or Morgan if any questions arise.

LPAs are requesting the following Administrator paperwork for Jessica Gram:
Administrator Documents
· LIC 308 (Designation of Facility Responsibility)
· Active and Current Administrator Certificate
· First Aid Certificate
· Administrator Resume
· LIC 500 (Personnel Report)
· LIC 501 (Personnel Record)
· LIC 503 (Health Screening Report - personnel)
· Proof of TB test
· LIC 9182 (Criminal Record Exemption Transfer Request)
· LIC 508 (Criminal Record Statement)
· Copy of Driver's License or Passport that is not expired
· Copy of Board of Directors' Resolution meeting minutes signed (required for all corporations)

Continued on LIC809C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 08/15/2023 04:21 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: BLUFFS AT HAMILTON HILL, THE	FACILITY NUMBER: 216804066
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on Record Review and Observations made, Licensee did not ensure that Staff member 1 (S1), Staff Member 2 (S2) and Staff Member 3 (S3) had the proper background clearance needed to provide care at the facility. This poses an immediate health and safety risk to residents in care.
	POC Due Date: 08/16/2023
	Plan of Correction
1 2 3 4	Licensee to ensure that all individuals subject to a criminal record review receive proper clearance and are associated to facility per Title 22 regulations. Licensee to submit a detailed step by step plan for how they will ensure fingerprint clearance and association is complete for employees prior to them working. Plan to be submitted by POC due date of Wednesday, 08/16/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023

LIC809 (FAS) - (06/04)

Page: 2 of 5

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: BLUFFS AT HAMILTON HILL, THE	FACILITY NUMBER: 216804066
	VISIT DATE: 08/15/2023

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
26
27
28
29
30
31
32

Continued from LIC809C

Documents to be submitted to CCL by due date of Friday, 08/25/2023.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

**An immediate civil penalty in the total amount of $1,500.00 has been issued for a lack of criminal
record clearance as required for S1, S2, and S3 (See LIC421BG).**

LPAs unable to complete the Annual Inspection. Annual Continuation Visit to be conducted at a later date.

Exit interview conducted. Copy of report, LIC809D, LIC421BG, LIC811 (Confidential Names), Plan of Corrections, and Appeal Rights discussed and provided to Executive Director in Training. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023

LIC809 (FAS) - (06/04)

Page: 5 of 5