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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804066
Report Date: 11/22/2023
Date Signed: 11/27/2023 03:42:18 PM


Document Has Been Signed on 11/27/2023 03:42 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



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: 46DATE:
11/22/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Executive Director, Jessica GrahamTIME COMPLETED:
03:50 PM
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At approximately 2:20PM Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced to conduct a case management inspection. LPA met with Executive Director (ED), Jessica Graham, and discussed the purpose of the visit.

LPA returned to the facility for the purpose of amending a document from a visit dated 10/17/2023. This document requires amending due to the use of the improper civil penalty form. LPA is also requesting additional documentation from an incident that occurred 10/14/2023 and was received by CCL on 10/16/2023. LPA previously followed up on this incident in report dated 10/17/2023.

ED updated LPA on th
e SOC341 (Suspected Dependent Adult/ Elder Abuse) that was received by CCL on 10/16/2023 and was previously discussed on original report on 10/17/2023. LPA and ED discussed the incident and confirmed that there were not any witnesses to the incident. ED has not yet received the police report despite making multiple attempts to contact them. Per conversation with ED, outside caregiver returned to facility the day following the incident but was promptly removed from the facility grounds and has not returned to facility since.

LPA received documentation on residents care manager, chart notes following the incident, and The Bluffs Requirements for Private Duty Attendants (outside caregiver did not complete required portion of form). ED was unable to locate at time of meeting the internal investigation documentation but confirmed that LPA will receive them via email by the end of the week (between 11/27-12/01).
No deficiencies cited during visit.


LPA is requesting the following documents by 12/01/2023
Any internal investigation documents on outside agency caregiver
Files on outside caregiver

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Helena RummondsTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2023
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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