Inspection Reports for
The Bluffs at Hamilton Hill

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 was substantiated based on interviews, observations, and record reviews. The facility was found to have insufficient staffing, including no med tech on shift on certain dates, leading to residents being unable to receive medications as needed.

The investigation substantiated the allegation that the facility did not ensure sufficient staffing, including the absence of a med tech on duty, resulting in residents missing medication and posing potential health and safety risks. A civil penalty of $250.00 was assessed for a repeat violation within 12 months.

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.

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.

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.

The complaint was substantiated based on evidence that staff response to a resident's call bell took 1 hour and 20 minutes, exceeding timely response standards.

The investigation substantiated the complaint that staff took 1 hour and 20 minutes to respond to a resident's call bell, posing 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 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 a self-reported incident of resident elopement on 02/14/2025. The complaint was substantiated as a deficiency was cited for failure to provide adequate supervision.

The facility failed to provide adequate supervision to a resident diagnosed with dementia, resulting in an elopement from the community. The resident was found safe off premises and returned without need for medical attention. The facility conducted in-service training for memory care 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 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 was triggered by allegations that the facility did not use proper infection control protocols and did not provide sufficient staffing. Both allegations were found unsubstantiated. However, an additional allegation regarding personal rights was substantiated because the facility failed to report to a responsible party in a timely manner.

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 allegation regarding failure to report to a responsible party in a timely manner was substantiated, resulting in a deficiency citation related to residents' personal rights.

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 generally compliant with environmental, food storage, medication, staff training, and resident record requirements. However, a deficiency was cited due to a resident with dementia eloping from the facility and being found outside the community grounds, posing an immediate health and safety risk.

Complaint was substantiated. The allegation was that the facility failed to notify the Responsible Person when resident R1 fell multiple times and was sent to emergency care on 4/22/2024. Evidence included incident reports and email correspondence confirming the failure to notify.

The complaint was substantiated based on review of incident reports and email communications showing failure to notify the Responsible Person of a medical emergency on 4/22/2024. The prior Executive Director apologized and additional staff training was provided. A deficiency was cited for failure to submit a written report within 7 days as required by regulation.

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 based on interviews, observations, and document review. Staff were found to administer medications improperly and leave residents in soiled clothing. Insufficient staffing was identified as a contributing factor. An immediate civil penalty of $250 was issued for a repeat violation.

The investigation substantiated the allegations that facility staff administered medications not as prescribed, left residents in soiled clothing for extended periods, and failed to meet residents' needs due to insufficient staffing. A civil penalty was issued for a repeat violation.

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, 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 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 about a medication error. The report was substantiated as the facility did not comply with medication administration regulations, posing an immediate health and safety risk.

The facility failed to follow its procedure for catching pharmacy errors, resulting in a resident not receiving a prescribed routine medication due to it being incorrectly entered as a PRN medication in the EMAR. 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 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, 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 visit was complaint-related following an incident report and a suspected elder abuse report. The physical altercation involving Resident 2 was investigated, and the caregiver was suspended. The incident was reported to Novato Police Department. The complaint was substantiated by the facility's actions and issuance of a civil penalty.

The facility failed to timely report an incident involving a missed medication dose for Resident 1 and had a physical altercation involving Resident 2 and an outside caregiver. The caregiver was suspended and a civil penalty of $250 was issued for repeat violations.

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 facility was found to have deficiencies related to medication administration where medications for two residents were not administered as required, posing potential health and safety risks. Incident reports involving resident falls and medication errors were reviewed, and plans of correction were requested.

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 found deficiencies related to staff files, including missing proof of negative TB tests, health screenings, and current First Aid/CPR certifications. One staff member was not fingerprint cleared or associated with the facility and was immediately removed. A civil penalty of $1,000 was issued due to 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 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 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.