Inspection Reports for
The Bluffs at Hamilton Hill

No deficiencies were cited during the visit. The Licensing Program Analyst was unable to interview two staff members as they were not on shift but made observations and obtained contact information.

The complaint alleged inadequate food services, including late breakfast and insufficient feeding assistance, and inadequate supervision due to lack of staff leaving residents alone. The investigation reviewed records, interviews, and observations but found no preponderance of evidence to support the allegations. The complaint was unsubstantiated.

The investigation found that food services were provided within the required 15-hour timeframe between the third and first meal, and staffing levels were adequate based on staff schedules and resident care plans. There was insufficient evidence to substantiate the allegations, resulting in an unsubstantiated finding.

The complaint involved a resident (R1) who fell when a wheelchair moved out from under them during a transfer by staff (S1). The resident was semi-wedged between the toilet and the wall, reported discomfort in the right shoulder, and requested 911 assistance. The incident was self-reported via a special incident report (SIR) received on 2026-01-26.

No deficiencies were cited during the visit. The report detailed the incident where a resident fell during a transfer and required 911 assistance. The resident was receiving physical therapy and was assessed for pain.

The Executive Director stated he has taken over staff scheduling and hired two new directors to oversee assisted living and memory care. No deficiencies or violations were explicitly stated in the report.

The complaint was substantiated. Residents experienced delayed responses to call buttons, with documented wait times of 2 hours and 50 minutes and one hour respectively.

The investigation found that residents experienced significant delays in response times to call buttons, with one resident waiting 2 hours and 50 minutes and another waiting one hour for assistance. The allegations were substantiated based on observations, interviews, and record reviews.

The complaint was substantiated based on evidence that staff mismanaged resident medication and failed to follow reporting requirements. The investigation included interviews, document reviews, and observations.

The investigation substantiated the allegations that resident R1 did not receive prescribed morphine medication on multiple occasions due to staffing issues, and the facility failed to submit required incident reports for these missed medications, posing health and safety risks.

The complaint alleged that staff did not maintain residents' confidential information. The investigation was unsubstantiated due to insufficient evidence to prove the violation occurred.

The investigation found contradictory information and a lack of corroborating evidence to support the allegation. Interviews with residents revealed no names were overheard during conversations about a resident transitioning off hospice, leading to the allegation being unsubstantiated.

The visit was complaint-related, following up on an incident where staff were reported to have aggressively pulled bed covers, physically restrained, and yelled at a resident. The complaint was substantiated by the facility's internal investigation and staff actions.

No deficiencies were cited during the visit. The facility confirmed an internal investigation was conducted, staff involved were suspended or no longer employed, and all required notifications were made per Title 22 Regulations.

Complaint was substantiated based on observations, interviews, and record reviews. The allegation was that staff did not follow personnel requirements, including understaffing and lack of medication dispensing training on the night shift of 2025-10-10.

The investigation substantiated the complaint that on the night of 2025-10-10, the night shift was understaffed with only three caregivers present and no medication technician. The caregivers on duty lacked training to dispense medication, posing a potential health and safety risk to residents.

The complaint alleging staff were not able to answer call buttons in a timely manner was substantiated based on interviews, observations, and record reviews.

The investigation found substantiated evidence that staff failed to respond to resident call buttons in a timely manner, with documented response times of 19, 39, and 53 minutes, posing a potential risk to resident health and safety.

The visit was triggered by a self-reported incident involving a resident with dementia who eloped from the facility. The resident was gone for approximately one hour without supervision. The door alarm was activated but staff did not observe the resident leaving at the time.

The facility failed to ensure staff were aware when the resident left the building without assistance, posing an immediate health and safety risk. A coordinated search was conducted, and the resident was safely returned and given antianxiety medication. The facility conducted in-service training on elopement.

The visit was complaint-related, following a self-reported incident of a resident with dementia who eloped from the facility unassisted. The incident was substantiated by the findings.

The facility failed to ensure staff awareness when the resident left the building without assistance, posing an immediate risk to health, safety, or personal rights. The resident was missing for approximately one hour, and although a door alarm was activated, staff did not observe the resident leaving. In-service training regarding elopement was conducted on 09/04/2025 and 09/09/2025.

The complaint was substantiated. Staff did not ensure resident R1 received timely assistance with incontinence care, with documented delay of 47 minutes in response to a call for help. Additionally, R1's mattress was found saturated with urine multiple times before being replaced on 07/07/2025.

The investigation substantiated the allegations that staff failed to provide timely incontinence care to resident R1 and that R1's mattress was saturated with urine before being replaced. Evidence included interviews, document reviews, and observations.

The complaint alleged lack of supervision leading to multiple falls of a resident. The allegation was found unsubstantiated due to lack of preponderance of evidence.

The investigation included interviews, document reviews, and observations. The resident had eight documented falls in 2025, and the facility updated the resident's Needs and Service Plan multiple times to address fall prevention. Despite the allegation, there was insufficient evidence to substantiate the complaint, and it was determined to be unsubstantiated.

The facility was found to be in compliance with no deficiencies cited during the inspection. The environment was safe and comfortable, medications were properly stored and recorded, and staff had required training and certifications. Updated documents were requested for submission by 08/02/2025.

The complaint involved a resident reporting that staff yelled at them and snatched and threw their glasses. The facility is investigating if a one-on-one caregiver was present during the incident. The investigation is ongoing.

The facility is conducting an ongoing investigation regarding an incident where a resident alleged that staff yelled at them and threw their glasses. No deficiencies were cited during this visit.

The facility is conducting an ongoing investigation regarding an incident where a staff member allegedly yelled at a resident and threw the resident's glasses. No deficiencies were cited during this visit.

The complaint involved a resident reporting that a new male caregiver was abrasive, yanked the resident's arms, placed blankets over their head, and left slamming the door. The caregiver reportedly told the resident "don't speak to me that way." The complaint was investigated and no deficiencies were found.

The Licensing Program Analyst conducted interviews and gathered documents related to the incident. No deficiencies were cited during the visit.

Complaint was substantiated based on evidence that staff response to residents' call alarm was delayed by 1 hour and 20 minutes.

The investigation substantiated the complaint, finding that staff took 1 hour and 20 minutes to respond to a resident's call for assistance, which poses a potential risk to resident health and safety.

The visit was complaint-related, following an incident report received on 2025-02-21 regarding a resident elopement on 2025-02-14. The resident diagnosed with dementia was unable to leave the facility unassisted. The complaint was substantiated as a deficiency was cited.

The facility failed to provide adequate supervision to Resident 1, resulting in an elopement from the community. The resident was found safe off premises and returned without medical need for emergency care. The facility conducted in-service training for memory staff and all staff elopement training following the incident.

The complaint investigation addressed allegations that the facility did not use proper infection control protocols and did not provide sufficient staffing. Both allegations were found unsubstantiated. A separate allegation regarding personal rights was substantiated due to failure to timely notify the responsible party of a resident's COVID diagnosis and unresponsiveness.

The investigation found the allegations of improper infection control protocols and insufficient staffing to be unsubstantiated due to lack of preponderance of evidence. However, a separate complaint regarding failure to promptly notify a resident's responsible party was substantiated, resulting in a cited deficiency related to personal rights communication.

The facility was found to be generally compliant with requirements including food storage, medication management, staff training, and resident records. However, a deficiency was cited due to a resident with dementia eloping from the facility, posing an immediate health and safety risk.

The facility was found to have an emergency disaster plan and infection control plan as required. All staff on-site were background cleared and associated with the facility. No deficiencies were cited during the visit. The annual inspection was not completed and a continuation visit will be conducted later.

Complaint was substantiated. Complainant alleged R1 fell multiple times and was sent to emergency care on 4/22/2024 without notification to the Responsible Person. Evidence reviewed included incident reports and email communications confirming the failure to notify.

The complaint was substantiated based on review of incident reports and email communications showing that a resident (R1) fell and was sent to emergency care on 4/22/2024 without notifying the Responsible Person. Additional training was provided to staff following the incident.

The complaint was substantiated. Evidence showed medication errors and residents left in soiled clothing due to insufficient staffing. An immediate civil penalty of $250 was issued for a repeat violation of regulation 87465(a)(4).

The investigation substantiated the allegations based on interviews, observations, and document reviews, finding that medications were administered more frequently than prescribed and residents were left in soiled clothing due to insufficient staffing. Deficiencies were cited under California Code of Regulations.

The visit was triggered by a complaint incident report dated 02/22/2024, substantiated by the finding that a resident drank another resident's medication without an order. An immediate civil penalty was issued.

The facility failed to comply with medication administration regulations, as a medication technician left medication accessible to residents, resulting in a resident consuming medication not prescribed to them. An immediate civil penalty of $250 was issued for a repeat violation.

The visit was complaint-related based on an Incident Report about a medication error. The report indicates a repeat violation and an immediate civil penalty was issued.

The facility failed to follow its procedure to catch a pharmacy error where a resident's routine medication order was incorrectly entered as PRN and not dispensed since 2023-11-20. An immediate civil penalty of $250 was issued for a repeat violation of regulation 87465(a)(4).

No deficiencies were cited during the visit. The Licensing Program Analyst discussed the incident with the Executive Director, confirmed no witnesses were present, and noted that the outside caregiver was removed from the facility and has not returned. Documentation related to the incident and caregiver was reviewed, and additional internal investigation documents were requested.

The visit was complaint-related, following an incident report and a Suspected Dependent Adult/Elder Abuse report. The physical altercation involving Resident 2 and an outside caregiver was investigated; the caregiver was suspended and authorities were notified. The complaint was substantiated by the findings.

The facility failed to timely report incidents to Community Care Licensing and failed to administer scheduled medication to a resident, posing health and safety risks. Additionally, a physical altercation involving a resident and an outside caregiver was investigated, resulting in suspension of the caregiver and notification of authorities.

The facility was found to have deficiencies related to medication administration for two residents, posing potential health and safety risks. Incident reports involving resident falls and medication errors were reviewed. The facility was required to submit a plan of correction and additional documentation for administrator change and facility updates.

The inspection found multiple deficiencies related to staff files, including missing proof of negative TB tests, missing health screenings, missing First Aid/CPR certifications, and one staff member not fingerprint cleared or associated with the facility. A civil penalty of $1,000 was issued for a repeat violation regarding background clearance.

The facility was generally found to be clean, safe, and well-maintained with adequate supplies and proper environmental conditions. However, deficiencies were cited related to staff fingerprint clearance and association with the facility, posing an immediate health and safety risk. An immediate civil penalty was issued for lack of criminal record clearance for three staff members.

The complaint was substantiated. The allegation that staff failed to respond to resident care needs was found valid based on evidence including inoperable staff pagers and lack of proper equipment for caregiving staff to respond to call lights.

The investigation substantiated the complaint that staff failed to respond to resident care needs due to inoperable staff pagers and caregiving staff not being properly equipped with call pagers, posing a potential health and safety risk to residents.

The facility was found to be clean, in good repair, and compliant with regulations including hot water temperature, food storage, PPE training, and safety equipment. No deficiencies were observed or cited during the inspection.

The facility was found to be in good repair with appropriate safety measures, infection control plans, and adequate supplies. No deficiencies were cited during this pre-licensing inspection.

The applicant and administrator successfully completed Component II, demonstrating understanding of facility operation, admission policies, staffing requirements, restrictive health conditions, general provisions, emergency preparedness, complaints and reporting, and pre-licensing readiness.