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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216804066
Report Date: 07/16/2024
Date Signed: 07/16/2024 03:38:11 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
05/21/2024 and conducted by Evaluator Helena Rummonds
COMPLAINT CONTROL NUMBER: 21-AS-20240521145945
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: 41DATE:
07/16/2024
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Regional Director of Sales and Operation, Lori Spencer TIME COMPLETED:
03:40 PM
ALLEGATION(S):
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Facility staff does not administer resident's medication as prescribed.
Staff left residents in soiled clothing for an extended period of time.
Facility staff are not ensuring that residents needs are met.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced at approximately 1:30PM to deliver findings regarding the above allegations. LPA and Regional Director of Sales and Operations, Lori Spencer discussed the purpose of the visit.

Throughout the course of the investigation, LPA conducted interviews, made observations, and reviewed documents.

Complaint alleges that facility staff does not administer resident's medication as prescribed. Per document review, facility was notified by their pharmacy that they were unable to refill a medication as the facility had requested a refill 10 days early, evidencing that medication(s) were being administered more frequently than prescribed. Interviews conducted revealed that staff members have witnessed medications being administered not as prescribed.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Helena RummondsTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 21-AS-20240521145945
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 07/16/2024
NARRATIVE
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Continued from LIC9099

Complaint alleges that staff left residents in soiled clothing for an extended period of time and that facility staff are not ensuring that residents needs are met. 4 of 6 staff interviews conducted revealed that they have witnessed residents being left in soiled clothing. Interviews conducted revealed that insufficient staffing contributes to residents needs not being met.

Based on interviews conducted, documents reviewed, and record review, the preponderance of evidence standard has been met, therefore the above allegations were found to be SUBSTANTIATED. Deficiencies are cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

**An immediate civil penalty in the total amount of $250 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), Plan of Corrections, and Appeal Rights discussed and provided to Regional Director of Sales and Operations. 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: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 21-AS-20240521145945
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/17/2024
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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Licensee to submit a self-certification stating they will do the following: conduct a weekly medication room audit which includes service plans. Self certification is due by POC due date of 7/17/2024.
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This requirement was not met as evidenced by: Based on document review and interviews conducted, the licensee did not comply with the section cited above by medications being administered not as prescribed.
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Type B
07/30/2024
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... This requirement has not been met as evidenced by:
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Licensee to submit proof of in-service training reviewing incontinence care to meet the needs of residents. Licensee to have meeting with direct care staff to discuss where care staff need additional support. Licensee to provide additional staffing and any additional supports identified during meeting.
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Based on interviews conducted, facility has insufficient staffing to provide the services necessary to meet the needs of the residents.
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Licensee to submit to LPA proof of both meetings indicating what topics were covered as well as names, dates, job titles, and signatures. Proof to be submitted for review and approval by POC due date of 07/30/2024.
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: 07/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
LIC9099 (FAS) - (06/04)
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