BLUFFS AT HAMILTON HILL, THE

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 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

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 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

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.