Shadow Ridge Senior Living

Allegation investigated: Personal Rights Personal Rights Staff did not observe changes in residents health condition Staff did not communicate changes with resident's responsible person Staff did not ensure medications were dispensed as prescribed Staff did not ensure residents records were properly maintained Staff did not assist resident with toileting needs Staff did not provide copies of records to residents responsible party

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to initiate a complaint investigation regarding the above-mentioned allegations. LPA identified themselves and met with Executive Director Charles Bloom, to discuss the purpose of the visit and elements of the complaint. During the visit it was discovered that the resident in question lived at this location under previous ownership and under a different facility number. No records were found to show that the resident lived at this facility under the current facility number and ownership. The investigation has now been opened under the correct facility number. An exit interview was conducted with Executive Director Charles Bloom. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided and their signature on this report confirms receipt of the Licensee Rights. Unfoundedthe state’s words, verbatim · CDSS document, Jul 30, 2026 · control 08-AS-20260727160359

Type of visit: Collateral

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced collateral visit to the facility regarding an unrelated complaint investigation. LPA Patterson identified themselves and stated the purpose of the visit to Executive Director Charles Bloom. During the visit, LPA Patterson interviewed staff and collected records. No deficiencies were observed during the visit. An exit interview was conducted with Executive Director Charles Bloom. A copy of this report along with Licensee/Appeal Rights (LIC9058 03/22) was provided at the conclusion of the visit. The signature below confirms the receipt of the documents.the state’s words, verbatim · CDSS document, Jul 30, 2026

Allegation investigated: Facility elevators not maintained in good repair

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced visit to conduct a complaint investigation and delivered findings regarding the above mentioned allegation. LPA was welcomed by, identified themselves to, and discussed the purpose of their visit to Executive Director Charles Bloom. Note, LPA did step out for lunch from 12:30-1:30pm. On 06/15/2026, the Department received a complaint where it was alleged that the two (2) facility elevators have been alternating being out of order since May, and at one point, both had been out of order at the same time, raising concern for non-ambulatory residents on the second floor. The Department’s investigation consisted of an unannounced facility visit, records review, and interviews with staff, residents, and outside sources. [Continued on LIC 9099-C] Unsubstantiated [Continued from LIC 9099] LPA conducted a brief tour of the facility and observed one operational elevator and one that was out of order. The non-operational elevator had appropriate signage to indicate it was out of order in addition to caution tape and an orange cone. LPA also observed a stairchair present in a stairwell inspected. Review of the facility's resident roster revealed that at least thirteen (13) residents on the second floor required some form of ambulation assistance, such as being wheelchair bound or requiring staff assistance for ambulation. It is worth indicating that the facility underwent a change in ownership officiated by the Department in mid-May 2026. Per an interview with administrative staff, one elevator broke down around March 2026 and the other around April 2026, revealing that the elevator breakdowns occurred under management by the former Licensee. Per the staff member, the second elevator broke down while the first was still non-operational (waiting for a special part) and so both elevators were down for a period of less than a day and a technician was able to repair one elevator. It was also revealed during the interview that as the new Licensee/change of property ownership was being processed, it took time to determine which party (new/current Licensee, former Licensee, or former property owner) was responsible for the elevator repair payment. File review of work orders for the two elevators from an elevator repair company, dated 5/28/26, detailed the work and costs necessary to repair the two elevators. Date of acceptance by the facility for the work needed was listed as 6/11/26. Review of payment receipts submitted by the facility to the repair company were dated for 6/15/26 and 6/16/26. An outside source interview with the elevator repair company corroborated the few hours of time where both elevators were down until one was repaired. It was also revealed the facility initiated proactive repair work to prevent such an issue from occurring in the future. Interviews with multiple staff members also corroborated that only a few hours had passed with both elevators down, with one mentioning that staff began conducting room checks, staff accompanied residents up and down stairs for safety, and staff utilized stairchairs for non-ambulatory residents. [Continued on LIC 9099-C] [Continued from LIC 9099-C] Interviews with residents and additional outside sources did not reveal any concerns about the elevators. One shared that the facility communicated that they were waiting on parts to repair the elevator. The facility had demonstrated that it was aware of the work needed for the elevators' repair and has taken timely action to do so, especially considering the complexity of the repair process, such as assessment of the issues, payment processing, city permitting, etc.. Based on interviews and records review, while the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred – therefore the allegation has been determined to be UNSUBSTANTIATED. An exit interview was conducted with Executive Director Bloom to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Jun 25, 2026 · control 08-AS-20260615160516

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Rebecca Borunda conducted an announced Pre-Licensing visit. LPA was met by Applicant Charles Bloom and was granted entry into the facility. The purpose of today's visit is to ensure that the facility is in compliance with California Code of Regulations, Title 22, Division 6. This is a change of ownership with residents in care and had a current census of 71 residents. The fire inspection was completed on 12/23/2025 and the facility is approved for a total of 160 residents, of which 128 may be non-ambulatory and 32 may be bedridden. The facility is also approved for delayed egress. During today's visit, LPA toured the facility and inspected a random sampling of resident rooms and bathrooms, common areas, kitchen, and outside space. The facility was found to be clean, safe, and in good repair with no pathway obstructions. Resident bathrooms were observed to be clean and the toilets and showers were found to be in working order. The facility's water temperature in private and common bathrooms were measured within regulatory requirements. LPA observed locked storage areas where all hazardous and/or toxic chemicals were stored and secured. LPA observed locked storage for resident medications and resident and staff paperwork. Fire extinguishers were observed throughout the facility and found to be in compliance. Functioning carbon monoxide detectors and smoke detectors were observed throughout the facility. No bodies of water were observed on the premises. LPA observed a 2-day supply of perishable and a 7-day supply of non-perishable food. Required postings were observed in a common area of the facility. LPA reviewed the facility’s Infection Control Plan and Emergency Disaster Plan, as well as a random sampling of resident and staff files. Continued on LIC809-C page... LPA conducted Component III with the applicant. The topics discussed were continuing operation requirements, record keeping/reporting, and physical plant compliance. Pre-licensing is complete, and this facility has no deficiencies. It is recommended that this facility be licensed pending final review and approval. An exit interview was conducted with Applicant Charles Bloom, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, May 1, 2026