Inspection Reports for The Bluffs at Hamilton Hill

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.

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 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 inspection was an unannounced complaint investigation triggered by an allegation regarding reporting requirements related to a resident's fall.

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.

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.

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.

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.

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.

An unannounced complaint investigation visit was conducted due to an allegation of lack of supervision resulting in multiple falls of a resident.

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

An unannounced Annual Required – 1 year inspection visit was conducted for this facility to evaluate compliance with licensing requirements.

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.

The visit was an unannounced Case Management - Incident inspection to follow up on a self-reported incident submitted to Community Care Licensing (CCL).

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.

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.

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.

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 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 visit was conducted as a Case Management - Incident follow-up on a self-reported incident involving a resident and a new male caregiver.

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

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.

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.

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.

The inspection was an unannounced visit to investigate a complaint alleging that staff were not adequately addressing a resident's fall risk.

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.

Complaint alleged that staff were not adequately addressing resident's fall risk. The allegation was unsubstantiated due to lack of corroborating evidence.

An unannounced visit was conducted to investigate a complaint alleging that staff did not respond to residents' call for assistance in a timely manner.

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.

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

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.

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 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 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.

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 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 inspection was an unannounced continuation of an Annual Required inspection initiated on 09/04/2024 to evaluate compliance with licensing requirements.

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.

An unannounced Annual Required 1-year inspection visit was conducted to evaluate compliance with licensing regulations and facility plans.

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.

Unannounced visit/investigation of a complaint received on 07/11/2024 regarding failure to report incidents as required by regulation.

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.

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 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.

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 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 inspection was conducted as a case management investigation on an incident report involving a resident drinking another resident's liquid medication without an order.

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.

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.

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.

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).

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 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.

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 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.

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 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 visit was an unannounced annual continuation case management inspection to evaluate compliance with licensing requirements and follow up on self-reported incidents.

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.

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.

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 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.

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.

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.

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 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 inspection was an unannounced Post Licensing visit conducted to evaluate the Elegance Hamilton Hill facility for compliance with licensing requirements.

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.

Pre-licensing inspection conducted to evaluate the facility's readiness for licensure and compliance with regulations.

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 visit was conducted as part of the original licensing process (Change of Ownership - CHOW) for the facility Elegance Hamilton Hill.

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.