BLUFFS AT HAMILTON HILL, THE

Official classification

Type B

Official code

1569.269(a)(6)

Regulation authority

HSC

What the official deficiency says

§1569.269 Enumerated rights... (a)Residents...shall have all of the following rights:(6) To care, supervision, and services that meet their individual needs...delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met by...... ....licensee as evidenced by: Based on LPA record review of facility's pendant call button system log, R1, R2, and R3s response time for assistance was between 2 - 4.5 hours, which poses a potentional risk to the health and safety of residents in care. *civil penalty in the amount of $250 is being assessed for repeat violation*

Official plan of correction

Licensee shall conduct training for all care staff on how residents pendant calls will be responded to in a timely manner and shall submit proof of completed training for all staff to Community Care Licensing (CCL) by 08/07/2026.

Deadline recorded: Aug 7, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(a)(4)

Regulation authority

HSC

What the official deficiency says

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidence by: Based on record review, R4 and R5 did not receive their mediciation, which poses a potentional risk to the health and safety of residents in care.

Official plan of correction

Licensee shall conduct training on medication management for all medication technicians. Proof of completed training shall be submitted to Community Care Licensing (CCL) by 08/24/2026.

Deadline recorded: Aug 24, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(d)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia:(d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement, as defined in Section 87101, Definitions. This requirement is not met as evidenced by: Based on records reviewed and interviews conducted, staff were not aware when R1 left the building and cleared the alarm without verifying which resident triggered it. This poses an immediate Health, Safety or Personal Rights risk to persons in care.

Official plan of correction

In-service training on elopement was conducted on 04/21/2026. POC cleared at time of visit.

Deadline recorded: Apr 28, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.269(a)(6)

Regulation authority

HSC

What the official deficiency says

§1569.269 Enumerated rights... (a)Residents...shall have all of the following rights:(6) To care, supervision, and services that meet their individual needs...delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs........ ....This requirement was not met by licensee as evidenced by: Based on LPA record review of facility's pendant call button system log, R1s bell response time was 2 hours and 50 minutes and R2s bell response time was one hour, which poses a potentional risk to the health and safety of residents in care.

Official plan of correction

Licensee shall conduct training for all care staff on how residents pendant calls will be responded to in a timely manner and shall submit proof of completed training for all staff to Community Care Licensing (CCL) by 01/12/2026.

Deadline recorded: Jan 12, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411(a) Personnel Requirements – General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based on record review, the facility did not ensure they had a med tech on duty resulting in R1 missing their medication, which poses an potential health and safety risk to residents in care. *civil penalty being assessed in the amount of $250.00* *LIC9099D amended to reflect correct civil penalty amount*

Official plan of correction

Licensee to submit plan of how facility will ensure facility has sufficient amount of staffing for all shifts to CCL by POC due date 12/29/2025.

Deadline recorded: Dec 30, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care 87465(a)(4) The licensee shall assist residents with self-administered medications as needed. This requirement not met by licensee as evidenced by: Based on document review of MAR, R1 was not administered their prescription medication on October 16th and November 22nd which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee to submit plan on how facility will ensure residents receive their prescription mediciation on time to CCL on POC due date 12/12/2025.

Deadline recorded: Dec 12, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence..... This requirement not met by licensee as evidenced by: Based on document review, facility did not send an incident report to CCL for missed medication for R1 on October 16th and November 22nd, which poses an potential health and safety risk to residents in care.

Official plan of correction

Facility to conduct training for all staff on reporting requirements and to send proof of completed training to CCL by POC due date 12/29/2025.

Deadline recorded: Dec 29, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411(a) Personnel Requirements – General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based on record review, the facility did not ensure staff on duty had training to dispense medication and/or had a med tech on duty which poses an potential health and safety risk to residents in care.

Official plan of correction

Facility to submit self-certification to CCL stating they understand regulation 87411(a) and submit an updated NOC shift schedule to ensure staff on duty have medication training by POC due date 12/09/2025.

Deadline recorded: Dec 9, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.269(a)(6)

Regulation authority

HSC

What the official deficiency says

§1569.269 Enumerated rights... (a)Residents...shall have all of the following rights:(6) To care, supervision, and services that meet their individual needs...delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met by licensee as evidenced by: Based on LPA record review of facility's pendant call button system log, R1 bell response time was 19 minutes, 39 minutes, and 53 minutes which poses a potentional risk to the health and safety of residents in care.

Official plan of correction

Licensee shall conduct all staff training on how residents pendant calls will be responded to in a timely manner and shall submit proof of completed training for all staff to Community Care Licensing (CCL) by 11/11/2025.

Deadline recorded: Nov 11, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(d)

Regulation authority

HSC

What the official deficiency says

87705 Care of Persons with Dementia:(d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement, as defined in Section 87101, Definitions. This requirement is not met as evidenced by: Based on records reviewed and interviews conducted, Licensee did not ensure staff were aware when R1 left the building without assistance. This poses an immediate Health, Safety or Personal Rights risk to persons in care.

Official plan of correction

In-service training was conducted on 09/04/2025 and 09/09/2025. POC cleared at time of visit.

Deadline recorded: Sep 10, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.269(a)(6)

Regulation authority

HSC

What the official deficiency says

§1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (6) To care, supervision, and services that meet their individual needs... This requirement is not met by licensee as evidence by record review and interviews...... conducted, the licensee did not ensure R1 received assistance from staff on duty and/or receive assistance in a timely manner. This poses an immediate Health, Safety or Personal Rights risk to persons in care.

Official plan of correction

Facility shall submit plan to CCL to conduct training for all direct care staff on care and supervision by plan of correction due date 09/05/2025. Facility to submit proof of completed training to CCL by 09/15/25.

Deadline recorded: Sep 5, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87625(b)(3)

Regulation authority

CCR

What the official deficiency says

87625 Managed Incontinence (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontience. This...... requirement is not met by licensee as evidence by record review and interviews conducted, the licensee did not ensure R1 had clean bedding as R1s mattress was saturated in urine. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Facility provided proof to LPA of new mattress ordered on 07/07/2025. POC cleared at time of visit.

Deadline recorded: Sep 3, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

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......Based on record review of alarm response system, facility did not ensure that staff responded in a timely manner to..... ......call system to assist resident in care. Residents bell response time was 1 hour and 20 minutes, which poses a potentional risk to the health and safety of residents in care.

Official plan of correction

Licensee shall conduct staff training on how call bells will be responded to and shall send proof of scheduled training to CCL by 04/18/25.

Deadline recorded: Apr 18, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411(a) Personal Requirements - General 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 evidence by: Based on incident report and interview, facility failed to provide supervision to R1 resulting in an elopement. The absense of supervision is an immediate risk to the Health, Safety and Rights of resident in care.

Official plan of correction

Cleared at time of visit. Facility conducted an in-service training about elopement procedures and has been completed for all memory care staff in the community.

Deadline recorded: Mar 13, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(9)

Regulation authority

HSC

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities:(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (9)To have communications to the licensee from their representatives answered promptly and appropriately. This requirment is not met as evidenced by: Based on document review and interviews conducted, facility did not ensure communication with R1’s representative was answered promptly and appropriately as required by regulation. This poses a potential health and saftey risk to residents in care.

Official plan of correction

Administrator agrees to submit a plan to address how staff will ensure timely communication with residents responsible parties to CCL by POC 12/13/24.

Deadline recorded: Dec 13, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(b)(2)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia: (b) In addition to the requirements as specified in Section 87208... plan of operation shall address... residents with dementia, including: (2) Safety measures to address behaviors such as wandering... This requirement is not met as evidenced by: Deficient Practice Statement Based on document reviewed, the Licensee did not comply with the section cited above. Resident 1 (R1) eloped from facility and was found walking outside of community grounds in a nearby neighborhood . R1’s Physician Report states they have dementia. This poses an immediate health and safety risk to residents in care.

Official plan of correction

POC Due Date: 10/04/2024 Plan of Correction Licensee to submit proof of scheduled training with all care staff regarding Elopement Procedures by POC due date of 10/04/2024.

Official classification

Type A

Official code

87211(a)

Regulation authority

CCR

What the official deficiency says

87211(a) A written report shall be submitted to the Licensing agency and to the person responsible for the resident within 7 days of the occurrence......Based upon documents reviewed, this requirement has not been met as evidenced by: R1 was transported for medical emergency on 4/22/24 and the Responsible Person was not notified by the facility. This posed an immediate risk to the personal rights of R1

Official plan of correction

Administration shall provide refresher training to staff on the requirements of 87211 and will provide proof of training to CCL by POC date in order to clear the deficiency.

Deadline recorded: Sep 12, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

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. 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.

Official plan of correction

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.

Deadline recorded: Jul 17, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

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: Based on interviews conducted, facility has insufficient staffing to provide the services necessary to meet the needs of the residents.

Official plan of correction

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. 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.

Deadline recorded: Jul 30, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

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. This requirement was not met as evidenced by: Based on document review, the licensee did not comply with the section cited above by R1 not being given medication as prescribed which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Facility conducted an in service medication training through an outside vendor which outlined proper medication procedures. Facility has since onboarded a nurse who will be assisting with medications. Deficiency cleared during visit.

Deadline recorded: Apr 6, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

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. This requirement was not met as evidenced by: Based on document review, the licensee did not comply with the section cited above by R1 not being given medication as prescribed which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Facility agrees to provide documentation outlining medication procedures when a new medication comes in from the pharmacy. Documentation to include their previous processes as well as an updated process to avoid medication errors in the future. Documentation to be provided to LPA by POC due date of 01/12/2024.

Deadline recorded: Jan 12, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

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. This requirement was not met as evidenced by: Based on document review, the licensee did not comply with the section cited above by R1 not being given medication as prescribed which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Facility to provide documentation showing that staff will be retrained. In service training to be conducted. Documentation to include: date of training, topics included, staff names, their job role, and signatures. Documentation to be submitted to CCL by POC due date of 10/18/2023 ***Civil Penalty assessed for a repeat violation of the same regulation within a 12 month period***

Deadline recorded: Oct 18, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (a)...licensee shall furnish to the licensing agency..., including...:(1) A written report shall be submitted to the licensing agency...within seven days of the occurrence of ...events specified in (A) through (D)...(D) Any incident which threatens the welfare, safety or health of any resident...This requirement was not met as evidenced by: Based on Incident report, the licensee did not comply with the section cited above by not reporting timely which poses a potential health and safety risk to persons in care.

Official plan of correction

Facility provided documentation showing that staff have been retrained. Deficiency cleared during visit. ***Civil Penalty assessed for a repeat violation of the same regulation within a 12 month period***

Deadline recorded: Oct 27, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Deficient Practice Statement Based on file review and observations made, the Licensee did not comply with the section cited above for 2 of 2 residents. LPAs observed that medications for 2 residents were not administered as required. This poses a potential health and safety risk to residents in care.

Official plan of correction

POC Due Date: 09/17/2023 Plan of Correction Licensee to submit a step by step plan detailing their new procedures for medication audits and in-service trainings for new hires. Plan to be submitted to CCL for review and approval by POC due date of 09/17/2023.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements:(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including...the following:(1)A written report shall be submitted to the licensing agency...within seven days of the occurrence of...(D) Any incident which threatens the welfare, safety or health of any resident... This requirement is not met as evidenced by: Deficient Practice Statement Based on file review and observations made, the Licensee did not comply with the section cited above for 2 of 2 residents. LPAs observed that medications for 2 residents were not administered as required. This poses a potential health and safety risk to residents in care.

Official plan of correction

POC Due Date: 09/17/2023 Plan of Correction POC: Licensee to provide training to all Staff reviewing the Regulation: 87211 Reporting Requirements. Inservice Training to include the following information: Date of Training, Training Topics, Job Role, Staff Names and Signatures. Training to be submitted to CCL for review and approval by POC due date of 09/17/2023.

Official classification

Type A

Official code

87355(e)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by: Deficient Practice Statement Based on Record Review and Observations made, Licensee did not comply with the section cited above and did not ensure that Staff Member 1 (S1) had the proper background clearance needed to work at the facility. This poses an immediate health and safety risk to residents in care.

Official plan of correction

POC Due Date: 08/22/2023 Plan of Correction Licensee to ensure that all individuals subject to a criminal record review receive proper clearance and are associated to facility per Title 22 regulations. Licensee to submit a detailed step by step plan for how they will ensure fingerprint clearance and association is complete for employees prior to them working. Plan to be submitted to Department by POC due date of Tuesday, 08/22/2023.

Official classification

Type A

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements – General (f) All personnel...shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure... This requirement is not met as evidenced by: Deficient Practice Statement Based on Records Review and Observations, the Licensee did not comply with the section cited above. LPAs observed that 2 of 6 staff files reviewed did not have a negative TB test on file. This poses an immediate health and safety risk to residents in care.

Official plan of correction

POC Due Date: 08/22/2023 Plan of Correction Licensee to submit self certification that all staff will have a health screening report and TB test on file as required by Title 22 Regulations. Proof of TB results for identified staff members to be submitted to Department by POC due date of Tuesday, 08/22/2023.

Official classification

Type A

Official code

87355(e)

Regulation authority

CCR

What the official deficiency says

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by: Deficient Practice Statement Based on Record Review and Observations made, Licensee did not ensure that Staff member 1 (S1), Staff Member 2 (S2) and Staff Member 3 (S3) had the proper background clearance needed to provide care at the facility. This poses an immediate health and safety risk to residents in care.

Official plan of correction

POC Due Date: 08/16/2023 Plan of Correction Licensee to ensure that all individuals subject to a criminal record review receive proper clearance and are associated to facility per Title 22 regulations. Licensee to submit a detailed step by step plan for how they will ensure fingerprint clearance and association is complete for employees prior to them working. Plan to be submitted by POC due date of Wednesday, 08/16/2023.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411(a)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: Based on LPA observation, faciltiy failed to respond to resident care needs due to 2 caregiving staff found to have not been equipped with call pagers. In addtion, 3 out of 3 pagers were found to be inoperable. This poses as a potential health & safety risk to residents in care.

Official plan of correction

Administrator has contacted Maintenance Services and placed order for new staff pagers, ensuring full operation. Training will be implemented for all staff on resident call light system and Regulation 87411-Personnel Requirements. Staff signatures submitted to CCLD by POC date 4/14/23. Administrator to develop written plan for device operation checks ensuring compliance. Plan by 4/14/2023.

Deadline recorded: Apr 14, 2023. A deadline is not proof that correction was completed.