Inspection Reports for The Bluffs at Hamilton Hill
1 Hamilton Hill Dr, Novato, CA 94949, United States, CA, 94949
Back to Facility ProfileInspection Report Summary
Most inspections found deficiencies related to resident supervision, medication management, and timely response to call lights, with several substantiated complaints about delayed assistance and elopements posing health and safety risks. The facility received multiple immediate civil penalties totaling at least $3,000 for repeat medication administration violations and fingerprint clearance issues for staff, along with fines of $1,000 and $1,500 for background clearance lapses in 2023. Several complaint investigations were unsubstantiated, including allegations about infection control and fall supervision. The most recent report from September 10, 2025, cited a deficiency for staff failing to notice a resident eloping from the memory care unit, posing an immediate risk, indicating ongoing challenges with supervision. While some earlier reports showed improvement, the pattern of supervision and resident care issues continues to recur.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
5.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
45% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
89% occupied
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Census: 85
Capacity: 95
Deficiencies: 1
Date: Sep 10, 2025
Visit Reason
The visit was an unannounced Case Management - Incident visit to follow up on a self-reported incident involving a resident who eloped from the memory care section of the facility.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Licensee did not ensure staff were aware when resident left the building without assistance, posing an immediate health, safety, or personal rights risk to persons in care.
Report Facts
Staff involved in search: 12
Staff involved in search: 18
Distance resident located from facility (miles): 0.5
Antianxiety medication water intake (ml): 120
Plan of Correction Due Date: Sep 10, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa M Lomeli | Administrator | Named as facility administrator. |
| Karina Vasquez | Business Manager | Met with Licensing Program Analyst during inspection. |
| Jose Acumabig | Executive Director | Met with Licensing Program Analyst during inspection. |
| Kimberley Mota | Licensing Program Manager | Named in report and deficiency section. |
| Anthony Loera | Licensing Program Analyst | Conducted the inspection and signed the report. |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 95
Deficiencies: 0
Date: Sep 3, 2025
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation regarding reporting requirements related to a resident's fall.
Complaint Details
The complaint alleged that the facility did not report a fall to the Power of Attorney/responsible party. Records showed the fall occurred on 07/16/2025, was reported to the resident's spouse who then notified the POA, and the facility contacted the POA/responsible party on the same day. The allegation was unsubstantiated.
Findings
Based on record review, interviews, and observations, the complaint allegations were found to be unsubstantiated as there was insufficient evidence to prove the alleged violation occurred.
Report Facts
Facility capacity: 95
Census: 85
Complaint control number: 21-AS-20250707082501
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anthony Loera | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Karina Vasquez | Business Manager | Met with Licensing Program Analyst during investigation |
| Sean Bannister | Memory Care Director | Met with Licensing Program Analyst during investigation |
| Lisa M Lomeli | Administrator | Facility administrator named in report header |
| Kimberley Mota | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 95
Deficiencies: 2
Date: Sep 3, 2025
Visit Reason
Unannounced complaint investigation visit conducted due to allegations that staff did not ensure resident's incontinence needs were met and that the resident had clean bedding.
Complaint Details
Complaint was substantiated. Allegations included failure to meet resident's incontinence needs and failure to provide clean bedding. Evidence showed delayed response to resident's call for assistance (47 minutes delay) and a urine-saturated mattress prior to replacement.
Findings
The investigation substantiated the allegations that staff failed to provide timely assistance for incontinence care and that the resident's mattress was saturated with urine before being replaced. Evidence included interviews, documentation review, and observations confirming these deficiencies.
Deficiencies (2)
Licensee did not ensure resident received timely assistance with incontinence care, posing immediate health, safety, or personal rights risk.
Licensee did not ensure resident had clean bedding; mattress was saturated in urine, posing potential health, safety, or personal rights risk.
Report Facts
Delay in assistance: 47
Capacity: 95
Census: 85
Plan of Correction due date: Sep 5, 2025
Plan of Correction proof due date: Sep 15, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anthony Loera | Licensing Program Analyst | Conducted complaint investigation and delivered findings |
| Kimberley Mota | Licensing Program Manager | Oversaw complaint investigation |
| Karina Vasquez | Business Manager | Met with Licensing Program Analyst during investigation |
| Sean Bannister | Memory Care Director | Met with Licensing Program Analyst during investigation |
| Lisa M Lomeli | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 95
Deficiencies: 0
Date: Aug 26, 2025
Visit Reason
An unannounced complaint investigation visit was conducted due to an allegation of lack of supervision resulting in multiple falls of a resident.
Complaint Details
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.
Findings
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.
Report Facts
Number of falls: 8
Facility capacity: 95
Census: 85
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anthony Loera | Licensing Program Analyst | Conducted the complaint investigation |
| Karina Vasquez | Business Manager | Met with Licensing Program Analyst during investigation |
| Kimberley Mota | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 86
Capacity: 95
Deficiencies: 0
Date: Jul 2, 2025
Visit Reason
An unannounced Annual Required – 1 year inspection visit was conducted for this facility to evaluate compliance with licensing requirements.
Findings
The facility was found to be in compliance with all licensing requirements. No deficiencies were cited during the inspection. The facility environment, food storage, medication management, staff training, and resident records were all found to be satisfactory.
Report Facts
Residents reviewed: 8
Staff records reviewed: 8
Hospice waiver capacity: 10
Fire extinguisher inspection date: 202409
Last fire drill date: Jun 30, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa M Lomeli | Administrator/Director | Named as facility administrator/director |
| Karina Vasquez | Business Manager | Met with Licensing Program Analyst during inspection |
| Jose Acumabig | Executive Director | Met with Licensing Program Analyst during inspection and exit interview |
| Anthony Loera | Licensing Program Analyst | Conducted the inspection |
| Kimberley Mota | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 83
Capacity: 95
Deficiencies: 0
Date: May 8, 2025
Visit Reason
The visit was an unannounced Case Management - Incident inspection to follow up on a self-reported incident submitted to Community Care Licensing (CCL).
Complaint Details
The visit was triggered by a self-reported incident. There were no witnesses to the incident, and the internal investigation is ongoing. Staff member S1 has been suspended during the investigation. The facility will provide CCL with the internal and police investigation findings once available.
Findings
No deficiencies were cited during the visit. The facility is conducting an ongoing internal investigation, and staff involved have been suspended pending the outcome. The Memory Care Director confirmed that investigation findings will be sent to CCL once completed.
Report Facts
Capacity: 95
Census: 83
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sean Bannister | Memory Care Director | Met with Licensing Program Analyst during the inspection and provided information about the incident and investigation |
Inspection Report
Complaint Investigation
Census: 83
Capacity: 95
Deficiencies: 0
Date: May 8, 2025
Visit Reason
The visit was an unannounced Case Management - Incident inspection to follow up on a self-reported incident submitted to Community Care Licensing involving a resident alleging staff misconduct.
Complaint Details
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.
Findings
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.
Report Facts
Capacity: 95
Census: 83
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sean Bannister | Memory Care Director | Met with Licensing Program Analyst during inspection and involved in exit interview |
| Anthony Loera | Licensing Program Analyst | Conducted the inspection visit |
| Lisa M Lomeli | Administrator/Director | Named as facility administrator/director |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 95
Deficiencies: 0
Date: May 6, 2025
Visit Reason
The visit was conducted as a Case Management - Incident follow-up on a self-reported incident involving a resident and a new male caregiver.
Complaint Details
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.
Findings
The Licensing Program Analyst conducted interviews and gathered documents related to the incident. No deficiencies were cited during the visit.
Report Facts
Incident report date: Apr 7, 2025
SOC341 report date: Apr 28, 2025
Incident date: Apr 2, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sean Bannister | Memory Care Director | Met with Licensing Program Analyst during the visit |
| Anthony Loera | Licensing Program Analyst | Conducted the inspection visit |
| Lisa M Lomeli | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 95
Deficiencies: 0
Date: Apr 10, 2025
Visit Reason
An unannounced visit was conducted to investigate complaints alleging that residents wandered away from the facility due to lack of supervision and that staff did not follow infection control practices.
Complaint Details
The complaint investigation was unsubstantiated based on lack of evidence supporting the allegations that residents wandered away due to lack of supervision and that staff failed to follow infection control practices.
Findings
The investigation found no corroborating evidence to support the allegations. Police logs showed no reports of missing residents, and staff interviews revealed no evidence of improper infection control practices. Therefore, the allegations were unsubstantiated.
Report Facts
Capacity: 95
Census: 86
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anthony Loera | Licensing Program Analyst | Conducted the complaint investigation |
| Kimberley Mota | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 95
Deficiencies: 0
Date: Apr 10, 2025
Visit Reason
The inspection was an unannounced visit to investigate a complaint alleging that staff were not adequately addressing a resident's fall risk.
Complaint Details
Complaint alleged that staff were not adequately addressing resident's fall risk. The allegation was unsubstantiated due to lack of corroborating evidence.
Findings
The investigation found contradictory information and a lack of corroborating evidence to support the allegation. The facility was observed to have caregivers assisting the resident with hourly checks and exploring one-to-one care options. The allegation was determined to be unsubstantiated due to insufficient evidence.
Report Facts
Capacity: 95
Census: 86
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anthony Loera | Licensing Program Analyst | Conducted the complaint investigation |
| Karina Vasquez | Business Director | Met with Licensing Program Analyst during investigation |
| Lori Spencer | Regional Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 95
Deficiencies: 1
Date: Apr 10, 2025
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging that staff did not respond to residents' call for assistance in a timely manner.
Complaint Details
Complaint was substantiated based on evidence that staff response to residents' call alarm was delayed by 1 hour and 20 minutes.
Findings
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.
Deficiencies (1)
Facility personnel did not ensure timely response to residents' call system, with a response time of 1 hour and 20 minutes.
Report Facts
Census: 86
Total Capacity: 95
Response Time: 80
Deficiency Due Date: Apr 18, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anthony Loera | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Kimberley Mota | Licensing Program Manager | Oversaw the complaint investigation |
| Karina Vasquez | Business Director | Met with Licensing Program Analyst during investigation |
| Lori Spencer | Regional Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 95
Deficiencies: 1
Date: Mar 13, 2025
Visit Reason
The visit was an unannounced Case Management - Incident visit to follow up on a self-reported incident involving a resident elopement that was submitted to Community Care Licensing.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Facility failed to provide supervision to Resident 1 resulting in an elopement, posing an immediate risk to the health, safety, and rights of the resident.
Report Facts
Deficiencies cited: 1
Distance resident found: 0.8
Capacity: 95
Census: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karina Vasquez | Business Director | Met with during inspection and provided information about the incident |
| Anthony Loera | Licensing Program Analyst | Conducted the inspection and authored the report |
| Kimberley Mota | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 95
Deficiencies: 1
Date: Dec 3, 2024
Visit Reason
The inspection was conducted as an unannounced complaint investigation visit triggered by allegations received on 2024-09-13 regarding improper infection control protocols and insufficient staffing at the facility.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Facility did not ensure communication with resident's representative was answered promptly and appropriately, violating personal rights regulations.
Report Facts
Capacity: 95
Census: 76
Plan of Correction Due Date: Dec 13, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anthony Loera | Licensing Program Analyst | Conducted the complaint investigation |
| Kimberley Mota | Licensing Program Manager | Oversaw the complaint investigation |
| Lisa Lomeli | Executive Director | Facility representative met during investigation |
| Karina Vasquez | Business Director | Facility representative met during investigation |
| Denise Muoz | Administrator | Facility administrator mentioned in report |
Inspection Report
Annual Inspection
Census: 69
Capacity: 95
Deficiencies: 1
Date: Oct 3, 2024
Visit Reason
The inspection was an unannounced continuation of an Annual Required inspection initiated on 09/04/2024 to evaluate compliance with licensing requirements.
Findings
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.
Deficiencies (1)
Resident 1 (R1) eloped from the facility and was found walking outside community grounds in a nearby neighborhood, posing an immediate health and safety risk to residents with dementia.
Report Facts
Staff records reviewed: 8
Resident records reviewed: 7
Food supply duration: 2
Food supply duration: 7
Water temperature range: 113.1
Water temperature range: 114.9
Fire extinguisher inspection date: 202409
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karina Vasquez | Business Manager | Met with Licensing Program Analyst during inspection and exit interview |
| Denise Muoz | Administrator/Director | Named as facility administrator/director |
| Anthony Loera | Licensing Program Analyst | Conducted inspection and authored report |
| Kimberley Mota | Licensing Program Manager | Supervisor and Licensing Program Manager overseeing inspection |
Inspection Report
Annual Inspection
Census: 69
Capacity: 95
Deficiencies: 0
Date: Sep 4, 2024
Visit Reason
An unannounced Annual Required 1-year inspection visit was conducted to evaluate compliance with licensing regulations and facility plans.
Findings
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 inspection was not completed and a continuation visit will be conducted later.
Report Facts
Bedridden capacity: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karina Vasquez | Business Manager | Met with Licensing Program Analysts during inspection |
| Lisa Lomeli | Executive Director/Administrator | New Administrator to be processed by Community Care Licensing |
| Denise Muoz | Administrator | Named as current Administrator in report header |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 95
Deficiencies: 2
Date: Sep 3, 2024
Visit Reason
Unannounced visit/investigation of a complaint received on 07/11/2024 regarding failure to report incidents as required by regulation.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Failure to submit a written report to the Licensing agency and the person responsible for the resident within 7 days of the occurrence as required by CCR 87211(a).
Responsible Person was not notified by the facility of the medical emergency on 4/22/24, posing an immediate risk to the personal rights of R1.
Report Facts
Capacity: 95
Census: 70
Deficiencies cited: 2
Plan of Correction Due Date: Sep 12, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Denise Muoz | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 95
Deficiencies: 2
Date: Jul 16, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that facility staff did not administer residents' medication as prescribed, left residents in soiled clothing for extended periods, and failed to ensure residents' needs were met.
Complaint Details
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).
Findings
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.
Deficiencies (2)
Medications were administered not as prescribed, violating CCR 87465(a)(4).
Insufficient staffing to meet residents' needs, violating CCR 87411(a).
Report Facts
Civil penalty amount: 250
Deficiency Type A Plan of Correction due date: Jul 17, 2024
Deficiency Type B Plan of Correction due date: Jul 30, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Helena Rummonds | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Victoria Bertozzi | Licensing Program Manager | Named in report as Licensing Program Manager |
| Lori Spencer | Regional Director of Sales and Operations | Met with Licensing Program Analyst during investigation and received report documents |
| Denise Muoz | Administrator | Facility Administrator named in report |
Inspection Report
Complaint Investigation
Census: 50
Capacity: 95
Deficiencies: 1
Date: Apr 5, 2024
Visit Reason
The inspection was conducted as a case management investigation on an incident report involving a resident drinking another resident's liquid medication without an order.
Complaint Details
The visit was complaint-related, triggered by an incident report received on 02/27/2024 regarding a resident drinking another resident's medication. The medication technician informed the primary care provider and resident's spouse, who stated no adverse effects would occur.
Findings
The facility failed to comply with medication administration regulations, as a medication technician left medication accessible, resulting in a resident consuming medication not prescribed to them. An immediate civil penalty was issued for a repeat violation.
Deficiencies (1)
Failure to comply with incidental medical and dental care requirements by not assisting residents with self-administered medications as needed, evidenced by a resident not being given medication as prescribed.
Report Facts
Civil penalty amount: 250
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Graham | Executive Director | Met with Licensing Program Analysts during inspection and discussed the incident |
| Helena Rummonds | Licensing Program Analyst | Conducted the inspection and signed the report |
Inspection Report
Complaint Investigation
Census: 52
Capacity: 95
Deficiencies: 1
Date: Jan 11, 2024
Visit Reason
The inspection was an unannounced case management visit conducted in response to an Incident Report regarding a medication error that occurred on 2023-12-15 and was received by the licensing agency on 2023-12-21.
Complaint Details
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.
Findings
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).
Deficiencies (1)
Resident was not given medication as prescribed due to pharmacy error and failure to follow facility procedure, posing an immediate health, safety, or personal rights risk.
Report Facts
Civil penalty amount: 250
Deficiency count: 1
Plan of Correction due date: Jan 12, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Graham | Executive Director | Met with Licensing Program Analyst during inspection and discussed medication error |
| Helena Rummonds | Licensing Program Analyst | Conducted the case management inspection and authored the report |
| Bethany Moellers | Licensing Program Manager | Named as supervisor and Licensing Program Manager on report |
Inspection Report
Census: 46
Capacity: 95
Deficiencies: 0
Date: Nov 22, 2023
Visit Reason
The visit was an unannounced case management inspection to amend a previous document from a visit dated 10/17/2023 and to request additional documentation related to an incident that occurred on 10/14/2023 involving an outside caregiver.
Findings
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.
Report Facts
Capacity: 95
Census: 46
Date of incident: Oct 14, 2023
Date of previous visit: Oct 17, 2023
Document submission deadline: Dec 1, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Graham | Executive Director | Met with Licensing Program Analyst during inspection and discussed incident |
| Helena Rummonds | Licensing Program Analyst | Conducted the case management inspection and requested additional documentation |
| Bethany Moellers | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 95
Deficiencies: 2
Date: Oct 17, 2023
Visit Reason
The visit was a Case Management - Incident unannounced inspection to follow up on an Incident Report from 09/09/2023 and a Suspected Dependent Adult/Elder Abuse report from 10/14/2023.
Complaint Details
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.
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.
Deficiencies (2)
Resident 1 did not receive a scheduled dose of morning medications due to staff unawareness of resident's new apartment location.
Facility failed to report incidents to licensing agency within the required seven days.
Report Facts
Civil penalty amount: 250
Deficiency count: 2
Plan of Correction due dates: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Graham | Executive Director/Administrator | Met with Licensing Program Analysts during the inspection and involved in incident follow-up. |
| Nathan Howland | Connections for Living Director | Met with Licensing Program Analysts during the inspection. |
| Bethany Moellers | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection. |
| Helena Rummonds | Licensing Program Analyst | Conducted the inspection and signed the report. |
Inspection Report
Annual Inspection
Census: 41
Capacity: 95
Deficiencies: 2
Date: Sep 7, 2023
Visit Reason
The visit was an unannounced annual continuation case management inspection to evaluate compliance with licensing requirements and follow up on self-reported incidents.
Findings
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.
Deficiencies (2)
Licensee did not comply with the requirement to assist residents with self-administered medications as needed for 2 residents.
Licensee did not comply with reporting requirements to submit written reports within seven days for incidents threatening resident welfare for 2 residents.
Report Facts
Residents in care: 41
Total capacity: 95
Staff on site: 48
Medication records reviewed: 2
Resident files reviewed: 6
Plan of Correction due date: Sep 17, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Graham | Executive Director | Met during inspection and discussed incident reports |
| Denise Munoz | Director of Administration | Acting Administrator during Executive Director's certification course |
| Kimberley Mota | Licensing Program Manager | Supervisor of licensing evaluation |
| Caitlynn Felias | Licensing Program Analyst | Conducted inspection and signed report |
Inspection Report
Annual Inspection
Census: 39
Capacity: 95
Deficiencies: 4
Date: Aug 21, 2023
Visit Reason
Unannounced Required 1 Year Visit (Annual Continuation) to evaluate compliance with regulations for a Residential Care Facility for the Elderly providing Assisted Living and Memory Care.
Findings
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.
Deficiencies (4)
Staff Member 1 (S1) was not fingerprint cleared or associated to the facility as required.
Two of six staff files reviewed did not have proof of a negative TB test on file.
Three of six staff files did not have proof of a health screening done.
Three of six staff files did not have proof of current First Aid/CPR certificates.
Report Facts
Civil penalty amount: 1000
Staff files reviewed: 6
Staff members on site: 14
Hospice waiver capacity: 10
Non-ambulatory resident capacity: 81
Bedridden resident capacity: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Graham | Executive Director | Met with Licensing Program Analysts during inspection. |
| Morgan Ware | Interim Executive Director | Met with Licensing Program Analysts during inspection and received report documents. |
| Caitlynn Felias | Licensing Program Analyst | Conducted inspection and authored report. |
| Kimberley Mota | Licensing Program Manager | Supervised inspection and cited deficiencies. |
Inspection Report
Annual Inspection
Census: 37
Capacity: 95
Deficiencies: 1
Date: Aug 15, 2023
Visit Reason
The inspection was an unannounced Required 1 Year Visit to evaluate compliance with regulations for a Residential Care Facility for the Elderly providing Assisted Living and Memory Care services.
Findings
The facility was generally found to be clean, safe, and well-maintained with adequate supplies and proper environmental conditions. However, deficiencies were cited for three staff members who were not fingerprint cleared or associated with the facility, posing an immediate health and safety risk. A civil penalty of $1,500 was issued for this violation. The annual inspection was not completed and will continue at a later date.
Deficiencies (1)
Staff Member 1 (S1), Staff Member 2 (S2), and Staff Member 3 (S3) were not fingerprint cleared or associated to the facility as required by regulation.
Report Facts
Civil penalty amount: 1500
Census: 37
Total capacity: 95
Staff on site: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Denise Muoz | Administrator | Named as facility administrator |
| Karina Vasquez | Business Manager | Met with Licensing Program Analysts during inspection |
| Nate Howland | Memory Care Director | Met with Licensing Program Analysts during inspection |
| Christine Mancuso | Executive Director in Training | Met with Licensing Program Analysts during inspection and received report documents |
| Jessica Gram | New Executive Director (hired, not yet started) | New Executive Director whose paperwork was requested |
| Morgan Ware | Interim Executive Director | Available for emergencies until new Executive Director starts |
| Jose Garcia | Maintenance Director | Participated in facility walk-through with Licensing Program Analysts |
| Caitlynn Felias | Licensing Program Analyst | Conducted inspection and signed report |
| Kimberley Mota | Licensing Program Manager | Supervised inspection |
Inspection Report
Complaint Investigation
Census: 38
Capacity: 95
Deficiencies: 1
Date: Apr 7, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-10-31 alleging that staff failed to respond to resident care needs.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by inoperable staff pagers and staff not properly equipped with call pagers.
Report Facts
Staff pagers inoperable: 3
Caregiving staff without pagers: 2
Census: 38
Total capacity: 95
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Hogan | Executive Director | Met with Licensing Program Analyst during investigation |
| Dominic Tobola | Licensing Program Analyst | Conducted the complaint investigation |
| Kimberley Mota | Licensing Program Manager | Oversaw complaint investigation and signed report |
Inspection Report
Original Licensing
Census: 39
Capacity: 95
Deficiencies: 0
Date: Dec 29, 2022
Visit Reason
The inspection was an unannounced Post Licensing visit conducted to evaluate the Elegance Hamilton Hill facility for compliance with licensing requirements.
Findings
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.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin J. Hogan | Administrator | Met with Licensing Program Analyst during inspection and granted access to the facility. |
| Farhaan Sarangi | Licensing Program Analyst | Conducted the Post Licensing inspection. |
| Hope DeBenedetti | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Original Licensing
Census: 42
Capacity: 95
Deficiencies: 0
Date: Sep 12, 2022
Visit Reason
Pre-licensing inspection conducted to evaluate the facility's readiness for licensure and compliance with regulations.
Findings
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.
Report Facts
Residents under hospice: 5
Fire extinguisher last charged: 10
Fire sprinkler last inspection: 11
Medication supply: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susan Edwards | Executive Director | Met during pre-licensing inspection and involved in orientation |
| Katelyn Ledesma | Assistant Executive Director | Met during pre-licensing inspection and involved in orientation |
| Carla Fernandes-Goes | Licensing Program Analyst | Conducted the pre-licensing inspection |
| Bethany Moellers | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Original Licensing
Census: 38
Capacity: 95
Deficiencies: 0
Date: Aug 12, 2022
Visit Reason
The visit was conducted as part of the original licensing process (Change of Ownership - CHOW) for the facility Elegance Hamilton Hill.
Findings
The applicant and administrator successfully completed the Component II interview, demonstrating understanding of California Code Title 22 regulations including facility operation, admission policies, staffing, emergency preparedness, and complaints reporting.
Report Facts
Capacity: 95
Census: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susan Edwards | Administrator | Administrator participated in Component II interview and was verified |
| Ken Assiran | Applicant Representative | Applicant representative participated in Component II interview |
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