Cardinal Point at Mariner Square

Type of visit: Case Management - Other

On 04/16/2026, at 1:55 PM, Licensing Program Analyst (LPA) James Sampair arrived at the facility unannounced to amend and to deliver that amended Complaint Investigation Report (LIC 9099) originally issued on 02/11/2026 for complaint 15-AS-20260211152510. The LPA met with Executive Director (ED) Avon Nguyen and explained the purpose of the visit. During the visit, the LPA amended the 02/11/2026 LIC 9099 and delivered the amended LIC 9099 to the ED. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 16, 2026

Type of visit: Required - 1 Year

On 02/13/2026 at 8:30AM, Licensing Program Analyst (LPA) Andrew Christy arrived unannounced to conduct the 1-Year Annual Required inspection. LPA met with Executive Director, Avon Nguyen, and explained the purpose of the visit. The facility currently houses 95 residents with a max capacity of 153 residents. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. No bodies of water were observed. A comfortable indoor temperature is maintained at 69.0 degrees Fahrenheit. The hot water temperature in the residents’ shared bathroom was measured at 111.1 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of non-perishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 03/05/2025. At 11:00AM, LPA reviewed five (5) resident files and six (6) staff files. The emergency disaster plan was last reviewed 08/06/2025. Quarterly emergency drills were last conducted 10/29/2025. A review of resident medications and the Medication Administration Record (MAR) found no outstanding errors. Continued on LIC809C..... Continued from LIC809..... The following deficiency was cited during inspection: During record review of employees, it was revealed all but one employee had an application/LIC501 on file. While the facility was switching to electronic records, they have been switching management companies and as a result the form was inaccessible. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of this report, along with Appeal Rights, was provided to the Executive Director.the state’s words, verbatim · CDSS document, Feb 13, 2026

Allegation investigated: Staff not ensuring resident's personal property is kept safe and secure.

On 02/11/2026, at 3:45 PM, Licensing Program Analyst (LPA) James Sampair arrived unannounced to conduct this 10-day complaint visit. The LPA explained the nature of the visit with Executive Director (ED) Avon Nguyen. The complaint alleges that staff are not ensuring that Resident R1's personal property is kept safe and secure. The LPA interviewed R1, the ED, and Witness W1, a family member of R1. The ED and W1 stated that R1 is confused. There have been no thefts of her medication, money, or belongings by staff, nor has any staff member changed her thermostat without her knowledge. The data collected does not support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove it; therefore, the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 11, 2026 · control 15-AS-20260211152510

Allegation investigated: Staff are not Criminally Record Cleared

On 9/04/25 at 3:15 PM, Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct an initial 10-day complaint investigation and deliver findings in regard to the allegation above. LPA met with Gloria Wohlfarth, Businees Office DirectorAdministrator, informed her the reason for visit. During the visit LPA recieved the staff roster. S1 was identifed and is fingerprint cleared per the facility's Guardian staff roster. This agency has investigated the above complaint. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted, a copy of this report provided. Unfoundedthe state’s words, verbatim · CDSS document, Sep 4, 2025 · control 15-AS-20250827150454

Type of visit: Required - 1 Year

On 2/25/25, Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director, Avon Nguyen and explained the purpose of the visit. LPA toured the facility including but not limited to residents’ apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. The pool is fenced according to regulation. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 70 degrees F. The hot water temperature in a kitchen was measured at 108.3 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 4/24/25. Emergency Disaster Plan was last reviewed on 2/06/25. First aid kit was observed to be complete. Fire drill was last conducted on 11/20/24. LPA reviewed 5 residents records and 5 staff records, and all were complete. LPA also reviewed a sample of resident’s medications. First Aid kit was observed to be complete. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Feb 25, 2025

Type of visit: Required - 1 Year

On 2/27/24 at 11:00 a.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director, Avon Nguyen and explained the purpose of the visit. The facility’s fire clearance was approved for 153. LPA toured the facility including but not limited to 6 residents’ apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. A pool is located behind the building and is properly gated and fenced. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 70 degrees F. The hot water temperature in residents’ apartments was measured at 117.5 and 116.2 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 4/26/23. Emergency Disaster Plan was last posted on 6/23/23. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 2/21/24. LPA reviewed 5 residents records and 5 staff records, and all were complete. LPA also reviewed a sample of resident’s medications. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Feb 27, 2024

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Facility staff failed to follow reporting requirements

On 11/21/23 at 12:00 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to deliver findings on the above allegation. LPA met with Avon Nguyen, Administrator and explained the purpose of the visit. LPA reviewed C1’s file and found the facility followed all reporting requirements regarding the injury that occurred on 6/17/23 which included filing a LIC624 with CCL on 6/20/23 which is within the regulatory timeframe. This agency has investigated the allegation that facility staff failed to follow reporting requirements. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted, a copy of this report provided. Unfoundedthe state’s words, verbatim · CDSS document, Nov 21, 2023 · control 15-AS-20230626092628

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Facility did not provide adequate supervision which resulted resident being abused while in care

On 11/21/23 at 12:00 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to deliver findings on the above allegation. LPA met with Avon Nguyen, Adimistratorand explained the purpose of the visit. Over the course of this investigation, the Department reviewed facility, medical, and collateral agency records, interviews of current staff, agency staff and facility clients. According to the Department’s review of Alameda Police Reports, facility notes, and statements from the Complainant, Client 1 (C1)’s power of attorney, other facility clients (Clients C2 and C3), and caregivers (Staff S1, S2, S3, S4, S5, and S6) C1 is currently on hospice and spends most, if not all, of her time in bed. C1 has private caregivers in addition to the facility staff to assist in her care 24/7. ***report continues on LIC9099C*** Unsubstantiated ***report continues from LIC9099*** On 6/17/23 contracted care staff (S1) left C1’s room to get C1’s dinner. When S1 was returning to C1’s room she heard C1 yelling. Upon arrival S1 observed that C1 had a bump on her left forehead and a bruise on her left orbital. S1 called for back up and several facility staff arrived to assist. Staff applied an ice pack to C1’s forehead. C1 was not taken to the hospital per hospice order. S3 called Alameda Police Department (APD) who arrived at the facility and attempted to interview C1. C1 refused to be interviewed. On 7/27/2023 APD returned to the facility and interviewed C1. When asked about her injuries C1 stated that a “big and white” person did it but was unable to elaborate. APD confirmed through staff interviews that C1 does not have any “white” caregivers. On 8/07/23 the department went to S1’s apartment to perform a follow-up interview. When asked how did S1 think C1 sustained her injuries S1 stated that since C1 was lying on her right side facing the bedrail when she left to get dinner C1 probably bumped her head against the bedrail. Staff now place a pillow between C1 and the bedrail and there have been no further injuries. Interview with C2 who lives across the hall from C1 revealed that he often hears C1 “yelling and screaming” and that it is “a normal occurrence” for C1. The Department has investigated the allegation that the facility did not provide adequate supervision which resulted in resident being abused while in care. We have found the allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 21, 2023 · control 15-AS-20230626092628