Good Shepherd Vista

Allegation investigated: Staff did not seek medical attention for a resident in care. Staff did not prevent a resident in care from sustaining falls. Staff did not allow a resident to receive phone calls. Staff are not bathing a resident in care.

On 4/10/2026 at 9:00 AM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct a complaint investigation and to deliver complaint findings for the allegations above. LPA met with Caregiver/Lead Staff, Stephanie Griffiths, and explained the purpose of the visit. Administrator (ADM), Hasmin Koo, arrived at a later time. During the investigation, LPA interviewed 5 residents, ADM, 4 staff, contacted 2 witnesses via phone, and the complainant. LPA reviewed and obtained documents, including LIC500, the physician's report, care plan, house rules, conservatorship documents, court order documents, and emergency information. Report Continue on LIC9099C... Unsubstantiated Finding: Staff Did Not Seek Medical Attention for a Resident in Care – Unsubstantiated Program Analyst (LPA) interviewed four (4) staff members, all of whom stated that medical attention is sought promptly whenever a resident is injured, becomes ill, or expresses a need for medical care. Additionally, five (5) resident interviews indicated that staff do seek medical attention when needed. An interview with the complainant further confirmed that the facility did, in fact, seek medical attention for Resident 1 (R1) while in care. Finding: Staff did not prevent a resident in care from sustaining falls – Unsubstantiated Licensing Program Analyst (LPA) interviewed four (4) staff members, all of whom stated that residents identified as fall risks are provided with appropriate supervision and assistance in accordance with their care plans. Staff reported that preventative measures, including monitoring, reminders, and assistance with ambulation, are implemented to reduce the risk of falls. LPA also interviewed five (5) residents, who indicated that staff are available to assist when needed. Residents reported that staff respond to requests for help and provide support with mobility and daily activities. In addition, LPA reviewed relevant facility records, including but not limited to incident reports, care plans, and physicians’ reports. Documentation reviewed did not indicate that staff failed to implement appropriate fall prevention measures or that neglect contributed to resident falls. Report Continue on LIC9099C1... Finding: Staff did not allow a resident to receive phone calls- Unsubstantiated Licensing Program Analyst (LPA) interviewed four (4) staff members, all of whom stated that residents are permitted to receive phone calls. Staff reported that Resident 1 (R1) has, at times, refused to accept phone calls. LPA also interviewed five (5) residents, who indicated that they are allowed to receive phone calls and that staff do not restrict access. Residents further reported that R1 has declined phone calls on occasion. In addition, LPA reviewed relevant documentation, including court records. LPA observed a court order granting R1’s conservator the authority to deny and/or limit visitation and communication, including phone calls. Finding: Staff are not bathing a resident in care- Unsubstantiated Licensing Program Analyst (LPA) interviewed four (4) staff members, all of whom stated that residents are assisted with bathing in accordance with their needs and established shower schedules. Staff reported that assistance is provided twice a week or as required and that residents are encouraged to maintain personal hygiene. LPA also interviewed five (5) residents, who indicated that staff assists with bathing and that they can shower regularly. Some residents reported that they choose their preferred bathing times or occasionally decline assistance. In addition, LPA reviewed facility documentation, including shower schedules, which indicate that bathing assistance is scheduled and provided to residents as needed. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore these allegations are UNSUBSTANTIATED. No deficiencies are being cited on this date. Exit interview conducted. A copy of this report provided.the state’s words, verbatim · CDSS document, Apr 10, 2026 · control 15-AS-20260403165245

Allegation investigated: Staff are over medicating resident Staff are not providing adequate food service to resident Staff did not notify resident's authorized representative that resident went to the hospital Staff did not safeguard resident's personal belongings Staff did not ensure resident was bathed by a female Staff are inappropriately turning resident's phone off Staff are not allowing resident's to watch TV Staff did not ensure resident had privacy Staff did not ensure resident received her PNI

On 4/9/2026 at 9:55am, Licensing Program Analyst (LPA), L. Hall arrived unannounced to deliver a complaint findings for the allegations above. LPA met with Tracey Barrett, Caregiver, and explained the reason for the visit. During the course of the investigation the Department conducted interviews with staff (S1, S2, S3, and S4), witnesses, residents, obtained and reviewed records of the following documents: admission agreement, physician's report, identification and emergency contact, appraisal needs and services plan, court order documents, medication administration record (MAR), incident report, menu, facility roster, and personnel report (LIC500). Continued on LIC9099C. Unsubstantiated Continued from LIC9099. Allegation: Staff are over medicating resident. During interview W1 reported that resident is over medicated. During interviews S3 and S4 stated they are the staff that take care of R1. R1’s medication is prescribed by physicians. LPA reviewed medication administration record (MAR) and observed all medicines given were taken for December 2025 and January 2026. LPA observed W3 was oriented during interview. W3 stated she was told she was over medicated but feels fine. Allegation: Staff are not providing adequate food service to resident During interview W1 reported that staff are not providing adequate food by giving resident soup all the time. LPA reviewed the physician’s report dated 10/31/2025, which indicates R1 requires food to be pureed due to diagnosis. LPA also reviewed facility’s menu that laid out what was to be eaten for the week and there was a variety of foods being served. S2 stated during interview that R1’s food is normally pureed, but R1 also eats food that is very soft. During interview R1 stated the staff will tell her what food is being pureed and if R1 doesn’t have a taste for that the staff will accommodate the request. R1 stated she does not have a problem with the food that is being served. Allegation: Staff did not notify resident's authorized representative that resident went to the hospital LPA reviewed documentation that indicated R1 has a court ordered conservator. LPA also reviewed the incident report dated 11/27/2025, that was submitted by S1, indicating the conservator was notified about the hospitalization of the R1. During interview with W2 on 1/2/2026, it was revealed that the authorized representative was notified about the hospitalization. Continued on LIC9099C. Continued from LIC9099C. Allegation: Staff did not safeguard resident's personal belongings W1 stated during initial interview that staff did not safeguard resident’s clothing. W1 stated clothing was bought for R1 that should have been dry cleaned only and staff washed clothing. S1, S2, S3, and S4 stated all residents clothing is washed on site. S1 stated if clothing is to be dry cleaned the family would take care of that for the resident. Allegation: Staff did not ensure resident was bathed by a female W1 stated during interview that R1 was bathed by a male and W1 wasn’t sure if care plan states that can be done. S1 and S4 stated only females work on the side that R1 resides. R1 stated S3 assist her with bathing 2xs a week and more if she requests, and if S3 is not there S4 assist her with needs. Allegation: Staff are inappropriately turning resident's phone off W1 stated during interview that several times during visitation R1’s phone was found to be turned off, and he feels that staff are responsible. S3 and R1 stated during interviews that R1 has possession of her phone and staff does not touch it. During interview LPA observed R1 had her phone on her person. Allegation: Staff are not allowing residents to watch TV W1 stated during the interview that a male staff (unknown name) did not allow the residents to watch football because he was watching baseball. LPA observed during visit there was a television in two locations and there were only residents watching. Allegation: Staff did not ensure resident had privacy During interview W1 reported staff did not ensure R1’s privacy by a male staff Continued on LIC9099C. Continued from LIC9099C. staff walking into the bathroom and asking R1 if assistance was needed. S1 stated R1 rarely needs assistance with incontinence issues. R1 stated there is a pendant/buzzer to call staff if assistance is needed and doesn’t recall any male staff walking in on her. Allegation: Staff did not ensure resident received her PNI During interview W1 stated staff is not ensuring resident is receiving PNI. W2 and W4 stated R1 has a payee that handles her finances. W4 stated during interview on 1/5/2026, that he has been the R1’s payee since June 2024. W4 also stated that R1 requested to save any money left over due to everything is paid for at the facility. Based upon the interviews conducted during the investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit interview conducted and a copy of report was given.the state’s words, verbatim · CDSS document, Apr 9, 2026 · control 15-AS-20251230154642

Allegation investigated: Staff do not allow resident's husband to visit. Staff are neglecting resident

On 3/12/2026 at 3:00PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct complaint investigation and to deliver complaint findings for the allegations above. LPA met with Caregiver/Lead Staff, Stephanie Griffiths and explained the purpose of the visit. During the investigation, LPA interviewed 4 residents, 1 staff, 3 witnesses, and complainant. LPA reviewed and obtained documents including LIC500, physician's report, care plan, house rules, conservatorship documents, court order documents, and emergency information. Staff do not allow resident's husband to visit. LPA observed there is a court order granting R1's conservator the power to deny and/or limit visitations. Interview with W1 revealed that visitation for R1's husband was halted around January of 2026 for safety concerns as R1 had a choking incident from food brought by R1's husband. According to R1's physician's report, R1 is on a pureed diet. (Continue on LIC9099C...) Unsubstantiated Staff are neglecting resident Interview with residents revealed that staff are available when residents needs assistance. Interview with S1 indicated there are 3 caregivers in the AM shift, 2 caregivers in the PM shift, and 1 awake staff for night shift. S1 stated that AM and PM shifts overlaps and there are live-in caregivers on call for night shift. Interview with witnesses revealed that R1 has an outpatient team and home health nurse to assist R1 with medical and dental needs. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore these allegations are UNSUBSTANTIATED. No deficiencies are being cited on this date. Exit interview conducted. A copy of this report provided.the state’s words, verbatim · CDSS document, Mar 12, 2026 · control 15-AS-20260128143228

Type of visit: Required - 1 Year

On 02/05/2026 at 8:30AM, Licensing Program Analysts (LPAs) Andrew Christy and Grace Luk arrived unannounced to conduct the 1-Year Annual Required inspection. LPA met with Lead Staff, Stephanie Griffiths, and explained the purpose of the visit. Administrator Hasmin Koo arrived at 9:30AM. The facility currently houses 20 residents with a max capacity of 22 residents. LPAs 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 68.0 degrees Fahrenheit. The hot water temperature in the residents’ shared bathroom was measured at 107.8 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 01/08/2025 with a new appointment for servicing on 02/12/2026. At 11:15AM, LPA reviewed five (5) resident files and five (5) staff files, all found to be complete. The emergency disaster plan was last reviewed 08/10/2025. Quarterly emergency drills were last conducted 12/01/2025. A review of resident medications and the Medication Administration Record (MAR) found no outstanding errors. No deficiencies cited during visit. Exit interview conducted and a copy of this report was provided to the administrator.the state’s words, verbatim · CDSS document, Feb 5, 2026

Allegation investigated: Facility refusing to let resident return back home

On 9/24/25 at 2:00 p.m., 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 Stephanie Griffiths, Care Staff Facility Manager and explained the purpose of the visit. During the course of the investigation LPA interviewed W1, S1 and reviewed R1's file. Review of R1's file revealed that R1 has lived at the facility since 10/23/24. R1 is conserved by Alameda County and has been for over 5 years. S1 stated that R1's County Case Manager does not give permission for R1 to leave the facility with W1. 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 24, 2025 · control 15-AS-20250915154125

Allegation investigated: Facility staff neglect resident in care

On 9/24/25 at 2:00 p.m., 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 Stephanie Griffiths, Care Staff and explained the purpose of the visit. During the course of the investigation LPA interviewed W1, S1 and reviewed R1's file. R1 has lived at the facility since 10/23/24. R1's Physician's Report dated 7/16/24 states that R1 needs assistance with medication admistration, uses a walker for ambulation, is alert and oriented X3, no other medical conditions or concerns are noted. R1 does not have dental insurance. This agency has investigated the above complaint. We have found that the complaint was 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, a copy of this report provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Sep 24, 2025 · control 15-AS-20250915154125

Type of visit: Required - 1 Year

On 2/13/24, Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Hasmin Koo, Administrator and explained the purpose of the visit. LPA toured the facility including but not limited to residents’ bedrooms, bathrooms, activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. 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 the kitchen sink was measured at 110.5 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 1/8/25. Emergency Disaster Plan was last posted on 2/01/25. First aid kit was observed to be complete. Fire drill was last conducted on 12/20/24. 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 13, 2025

Allegation investigated: Staff did not follow proper emergency procedures as necessary.

On 8/08/24 at 11:00 a.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct an initial 10-day complaint investigation and deliver findings in regard to the allegations above. LPA met with Hasmin Koo and explained the purpose of the visit. During the investigation LPA interviewed the reporting party (RP) S1, S2, and R1. LPA interviewed S1. S1 stated that there is one awake overnight staff at the facility. On the morning of 7/28/24 S1 identified the staff on duty was S2. S1 also identified the resident who called 911 as R1. S1 stated that R1 is very independent and manages her affairs. R1 has a long history of calling 911, without telling the staff, from her private cell phone for minor ailments. On the morning of 7/28/24 R1 called 911 because she had a headache. ***report continues on LIC9099C*** Unsubstantiated ***report continues from LIC9099*** LPA interviewed S2 who stated he was on duty but not feeling well on the morning of 7/28/24 and was in the bathroom when Oakland Fire arrived at the facility. He estimates that it took him several minutes to get to the front gate. When he arrived there, he found the egress alarm had been triggered and saw R1 with Oakland Fire personnel being evaluated. S2 stated that Oakland Fire took R1 to Alta Bates ER to be evaluated. LPA interviewed R1 who was in her bedroom at the facility. LPA observed that R1 had a cell phone on her night table. LPA asked R1 how she was feeling and R1 replied that she was “fine.” LPA asked R1 about calling 911. R1 stated that she calls 911 on her own because she “doesn’t want to bother the staff.” R1 had no complaints about her care at the facility. This agency has investigated the complaint alleging staff did not follow proper emergency procedures as necessary. We have found that the complaint was 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, a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 8, 2024 · control 15-AS-20240801154138

Type of visit: Required - 1 Year

On 2/15/24 at 11:45 AM, Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct 1-Year Annual Required inspection. LPA spoke with Hasmin Koo, Administrator on the phone who gave permission for care staff Stephanie Griffiths to sign the report. The facility’s fire clearance was approved for 22. LPA toured the facility including but not limited to bedrooms, bathrooms, activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. 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 kitchen sink was measured at 139.2 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 1/04/24. Emergency Disaster Plan was last posted on 11/01/23. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 12/02/23. LPA reviewed 5 residents records and 5 staff records and all were complete. LPA reviewed a sample of resident’s medications. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code. Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Feb 15, 2024

Allegation investigated: Facility staff did not safeguard resident's property.

On 12/27/23 at 1:45 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct an initial 10-day complaint investigation in regard to the allegation above. LPA met with Hasmin Koo, Administrator and explained the purpose of the visit. During the visit LPA interviewed S1. S1 stated that the staff at the facility deliver mail to R1 which includes his personal and incidental allowance checks. S1 further stated that once R1 has his check he leaves the facility the same day to cash his check. The facility does not handle cash resources for the residents. ***report continues on LIC9099C*** Unsubstantiated ***report continues from LIC9099*** The facility does laundry for the residents on a daily basis for most residents. R1 has his own laundry basket which the staff pick up upon request in the evening and return in the morning. Upon admission the facility puts the residents name in all of their clothing to help identify what items belong to what residents. R1 often accuses other residents of wearing his clothing and staff have to show him the name in the clothing to prove the clothing is not his. LPA reviewed R1’s file. R1 has been at the facility since 11/07/2022 and is able to leave the facility unassisted. The facility manages R1’s medication. R1 needs help with most of his activities of daily living. LPA also interviewed R1. R1 was able to tell LPA that he gets a $30 check weekly and cashes the checks at a check cashing place and buys cigarettes and personal items. R1 stated “they take everything I got” but was unable to provide LPA with any details. This agency has investigated the complaint alleging that facility staff did not safeguard resident's property. We have found that the complaint was 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, a copy of this report provided.the state’s words, verbatim · CDSS document, Dec 27, 2023 · control 15-AS-20231220151542