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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804066
Report Date: 01/11/2024
Date Signed: 01/11/2024 03:38:59 PM


Document Has Been Signed on 01/11/2024 03:38 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: 52DATE:
01/11/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Executive Director, Jessica GrahamTIME COMPLETED:
03:45 PM
NARRATIVE
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At approximately 2:30PM Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced to conduct a case management inspection on an Incident Report that occurred on 12/15/2023 and was received by CCL on 12/21/2023. LPA met with Executive Director (ED), Jessica Graham, and discussed the purpose of the visit.

Incident Report states that Resident 1s (R1s) order for routine Quetiapine was entered into the EMAR (Electronic Medication Administration Record) incorrectly by the pharmacy. The order was intended to be given as a routine medication and was entered as a PRN medication and not dispensed to resident since 11/20/2023.

Per conversation with ED, the facility has a procedure for catching any errors by the pharmacy which was not followed, resulting in the medication error. ED discussed with LPA that the medication technicians could not have prevented this error as they do not have the capability of altering medication orders in the EMAR.

**An immediate civil penalty in the total amount of $250.00 has been issued for a repeat violation of regulation 87465(a)(4). LIC421FC**

Exit interview conducted. Copy of report, LIC-809D, LIC421FC (Civil Penalty Assessment), LIC811 (Confidential Names), Plan of Corrections, and Appeal Rights discussed and provided to Executive Director. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Helena RummondsTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2024
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 2


Document Has Been Signed on 01/11/2024 03:38 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
SANTA ROSA RO, 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: 01/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/12/2024
Section Cited
CCR
87465(a)(4)

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87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall... provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed.
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Facility agrees to provide documentation outlining medication procedures when a new medication comes in from the pharmacy. Documentation to include their previous processes as well as an updated process to avoid medication errors in the future.
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This requirement was not met as evidenced by: Based on document review, the licensee did not comply with the section cited above by R1 not being given medication as prescribed which poses an immediate health, safety or personal rights risk to persons in care.
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Documentation to be provided to LPA by POC due date of 01/12/2024.

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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: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Helena RummondsTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2024
LIC809 (FAS) - (06/04)
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