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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804066
Report Date: 04/05/2024
Date Signed: 04/05/2024 03:07:51 PM


Document Has Been Signed on 04/05/2024 03:07 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
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: 50DATE:
04/05/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Executive Director, Jessica GrahamTIME COMPLETED:
03:25 PM
NARRATIVE
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At approximately 1:35PM Licensing Program Analysts (LPAs) Helena Rummonds and Jacky Macias arrived unannounced to conduct a case management inspection on an Incident Report that occurred on 2/22/2024 and was received by CCL on 02/27/2024. LPAs met with Executive Director (ED), Jessica Graham, and discussed the purpose of the visit.

Incident Report states that Resident 1 (R1) drank Resident 2 (R2s) liquid medication (citalopram 10mls). R1 did not have an order for the medication that was consumed. Medication Technician on duty informed R1s primary care provider and R1s spouse. PCP stated that there would be no adverse affects.

Per conversation with Executive Director, the medication technician placed the medication on the counter and turned around leaving the medication accessible to other residents when R1 drank the medication.

**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: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Helena RummondsTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2024
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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Document Has Been Signed on 04/05/2024 03:07 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: 04/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/06/2024
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 conducted an in service medication training through an outside vendor which outlined proper medication procedures. Facility has since onboarded a nurse who will be assisting with medications. Deficiency cleared during visit.
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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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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: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Helena RummondsTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2024
LIC809 (FAS) - (06/04)
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