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Inspection visit

complaint

BLUFFS AT HAMILTON HILL, THELicense 2168040662 citations on this visit
2 citations recorded

Inspector’s narrative

What the inspector wrote

Community Care Licensing (CCL) received a Special Incident Report (SIR) on 12/01/2025 regarding R1 missing their scheduled Morphine Sulfate 2.5mg dose. The SIR states the date it occurred on was 11/24/2025, but in the description of the incident it states, “It is noted that on Friday, November 12th, the resident’s scheduled Morphine Sulfate 2.5mg PO does was missed”. It is unclear what date the medication was exactly missed on as November 24th was a Monday and November 12th was a Wednesday. The dates given in the SIR are inaccurate. On October 20th, 2025, it is unclear if R1 received their morphine dose at 8:00am as staff notes state “short staff was passing meds upstairs”. Documentation for November 1st, 2025, at 8:00am, 8:30am, and 12:00pm, it is unclear if R1 received their routine morphine and Refresh Tears Ophth 0.5% drops as staff notes state “short staff”. It should be noted per R1s medication list, R1 is to receive morphine every four hours for pain management. For the dates of October 16th and November 22nd where documentation states R1 missed their medication, CCL did not receive a Special Incident Report (SIR). Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Division 6, Chapter1 is being cited on the attached LIC 9099D. Appeal rights given.

Citations

3 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 87411(a)Type B

    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*

  • 87211(a)(1)Type B

    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.

  • 87465(a)Type A

    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.

FAQ · About this visit

Common questions about this visit

What happened during the December 11, 2025 inspection of BLUFFS AT HAMILTON HILL, THE?

This was a complaint inspection of BLUFFS AT HAMILTON HILL, THE on December 11, 2025. 2 citations were issued: 1 Type A (serious) and 1 Type B.

Were any citations issued to BLUFFS AT HAMILTON HILL, THE on December 11, 2025?

Yes, 2 citations were issued (1 Type A, 1 Type B). The first citation was for: "87411(a) Personnel Requirements – General Facility personnel shall at all times be sufficient in numbers, and competent ..."

What type of inspection was this?

This was a complaint inspection. Complaint inspections are triggered when someone reports a concern about the facility to CCLD.

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.