Ivy Park at Cathedral Hill

Type of visit: Case Management - Legal/Non-compliance

On 8/31/2026, Licensing Program Analyst (LPA), Grace Donato conducted an unannounced case management- legal/non-compliance inspection to monitor the facility operation. LPA met with Executive Director, Chris Schuster, and explained the purpose of the visit. A non-compliance conference was held on 5/13/26. During non-compliance meeting, the following violations were discussed, Incidental Medical and Dental, Observation of Resident, Administrator Qualifications and Duties, Reappraisals, Additional Personal Rights of Residents in All Facilities, Personal Rights of Residents in All Facilities, Basic Services, and Personnel Requirements. On 5/27/2026, a compliance plan was submitted to CCLD by the Licensee. During the visit, LPA reviewed the compliance plan with the Administrator. LPA observed in-service training documentation about different topics under medication training, medical response, suicidal ideations, change in condition, resident rights, conducted between 5/8/2026 - 6/18/2026. Facility has a qualified administrator onsite which oversees training. ADL (Activities of Daily Living) checklist is checked by the Health Services Director (HSD) daily. New pagers and radios have been purchased and call system is checked monthly. LPA received an updated LIC500. LPA has reviewed three resident files and all the reappraisals are updated. No citations issued today. Report is reviewed with and a copy is provided.the state’s words, verbatim · CDSS document, Aug 31, 2026

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Grace Donato arrived on 8/10/2026 for an unannounced inspection to follow up on a substantiated allegation of a complaint investigation. LPA met with Executive Director, Chris Schuster and stated the purpose of this visit. On October 13, 2025, the Department concluded a complaint investigation and substantiated an allegation that lack of supervision resulted in resident falling and sustaining injuries. The licensee was cited for California Code of Regulations (CCR) Title 22, § 87466 Observation of the Resident and 87211(a)(1) Reporting Requirements. At the time of the complaint visit on December 23, 2025, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49(f). The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code § 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including, but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by the licensee failing to provide the appropriate care and supervision resulting in the resident sustaining 11 falls within a 14-month time period with one of the falls resulting in a brain bleed and a fracture of the right first distal phalanx (thumb). Today, 8/10/2026, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49(f) for a violation that the Department constitutes as a serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on December 23, 2025, the amount of the civil penalty issued today will be $9,500. Exit interview conducted. A copy of the report issued. Appeal rights provided. Chris Schuster's signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Aug 10, 2026

Allegation investigated: Facility did not provide proper notification to resident and/or their responsible party of charges relating to increase in care Facility adds unknown charges to residents' bills

On 8/4/2026, LPA Grace Donato conducted an unannounced complaint investigation visit. LPA met with Executive Director (ED) Chris Schuster and explained the purpose of the visit. For the allegation of Facility did not provide proper notification to resident and/or their responsible party of charges relating to increase in care, LPA interviewed three residents. R3 mentioned that there have been charges regarding care fees that was not discussed. R3 stated that he/she lives in assisted living but require no care. However, R3 hasn’t paid any of the care fees and has constantly talked with the facility to remove charges. LPA also spoke to the ED and mentioned that everything has been explained and settled with the residents having issues with billing. Unsubstantiated For the allegation of Facility adds unknown charges to residents' bills, R2 stated that there have been unknown charges in his/her billing statement. R2 hasn’t paid anything as he/she has discussed the charges. LPA also interviewed staff and S1 stated that they have explained the charges to the residents and that residents understood the breakdown of fees. Based on interviews and records review, the department has determined that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Report is reviewed and copy is provided.the state’s words, verbatim · CDSS document, Aug 4, 2026 · control 14-AS-20260601153300

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Grace Donato arrived on 8/4/2026 for an unannounced inspection to follow up on a substantiated incident report by the facility. On November 07, 2024, the Department concluded an incident report investigation regarding neglect/lack of supervision the resident committed suicide while in care. The licensee was cited for California Code of Regulations, Title 22 (22 CCR), Division 6, Chapter 8, § 87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities, CCR § 87466 Observation of the Resident, and CCR § 87463(a) Reappraisals. At the time of the case management visit on November 07, 2024, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49(e). The Department has concluded an analysis and has determined that a civil penalty is warranted for a violation that the Department determines resulted in the death of a resident. This is evidenced by the licensee failed to provide care and supervision when the facility was aware of the resident’s repeated suicidal statements that resulted in death. Today, 8/4/2026, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49(e) for a violation that the Department determines resulted in the death of a resident in the amount of $15,000. However, since an immediate civil penalty of $500.00 was previously issued on November 07, 2024, the amount of the civil penalty issued today will be $14,500. Exit interview conducted. A copy of the report issued. Appeal rights provided. Chris Schuster's signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Aug 4, 2026

Type of visit: Case Management - Incident

On 8/4/2026, LPA Grace Donato conducted an unannounced Case Management - Incident visit. LPA met with Executive Director (ED) Chris Schuster and explained the purpose of the visit. LPA received an incident report last July 8, 2026 stating that at 3:15pm, a resident (R1) requested to sit outside and wait for the scheduled walking group. The receptionist allowed R1 to exit. R1 exited the building and kept walking down the street. R1 was assessed after returning to facility and no injuries were found. According to interviews, Health and Services Director (HSD) stated that the staff wasn't aware of R1s diagnosis so they opened the door to let R1 out. On R1's medical assessment, R1 was not allowed to leave the facility unassisted. Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 9099D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed and a copy of report and appeals rights are provided.the state’s words, verbatim · CDSS document, Aug 4, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Aug 4, 2026

87464 Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by Based on interviews, R1 left the facility unassisted which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 4, 2026

Plan of correction: Facility has already corrected the citation by retraining all staff members about Elopement.

Allegation investigated: - Staff did not prevent a resident from blocking another resident from leaving their room - Staff did not prevent a resident from preventing another resident from speaking to health professionals

LPA Jeung interviewed staff and residents and observed room of client #1, who appeared well groomed. Based on review of facility records and interviews with residents and staff, this allegation is determined to be unsubstantiated. Although the allegations may have occurred or are valid, there is not enough evidence to prove the alleged violations did or did not occur. On 2/25/26, case manager and MD arrived to see client #1 for a scheduled appointment. Client was with another resident in another room, and was unaware of the appointment. Client was confused and not able to recognize the case worker or MD, but reluctantly agreed to exit room with case worker. Occupant/resident wanted client #1 to remain in the room, and demanded that the case worker leave. Occupant blocked the door so client #1 could not get past him, and pushed case worker towards the door. Case worker and MD left without fulfilling the appointment due to the volatility of the situation. Staff were not present during this encounter, but monitor and document clients' behaviors and care in charting notes. Client #1 stated to LPA during a prior meeting that she did not recall the incident in February. She also confirmed that she feels safe and is not being forced to do anything against her will. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 9, 2026 · control 14-AS-20260305124533

Allegation investigated: financial abuse to resident receiving care at the facilty

On 5/28/2026, Licensing Program Analyst(LPA) John Calandra arrived at the facility to deliver conclusionary findings for this complaint. LPA Calandra was greeted by Kelly Phillips, Health Services Director and explained the purpose of the visit. Complaint alleged that financial abuse occurred to a resident living at the facility. According to the reporting party, a resident(R1) of the facility had money stolen by someone identifying themselves as an employee of the facility. According to the Administrator, the incident occurred on a day when the only management staff in the building was the Sales Director who sat in their own office. According to the Administrator they reviewed surveillance footage after the incident and did not see anyone other than the Sales Director enter the business offices area of the facility. Based on interviews and record review, no other individuals were seen in the facility’s business office on the day in question. Although the above 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. Nothe state’s words, verbatim · CDSS document, May 28, 2026 · control 14-AS-20260330164331

Type of visit: Office

On 05/13/2026, San Bruno Regional Office conducted a non-compliance conference meeting with Chief Operations Officer, Matt Stevenson, Scott Carlson, Senior Vice President of Operations, Jenn Sato, Senior Vice President of Operations, Patricia Murphy, Regional Director of Operations, Safoora Ahmed, Vice President of Memory Care and Programming, Kevin Wrigley, Vice President of Regulatory, and Chris Schuster, Executive Director, and Joel Goldman, Partner at Hanson Bridgett LLP. Present in the meeting were Regional Manage Jackie Jin, Licensing Program Manager Brenda Chan, and Licensing Program Analyst John Calandra . During the non-compliance meeting, the following serious violations were discussed: 87465(h) Incidental Medical and Dental, 87466 Observation of Resident, 87405(a) Administrator Qualifications and Duties, 87463(a) Reappraisals, 87468.2(a)(4) Additional Personal Rights of Residents in All Facilities, 87468.1(a)(2) and 87468.1(a)(6) Personal Rights of Residents in All Facilities, 1569.312(a) Basic Services, and 87411(a) Personnel Requirements. During this meeting, the compliance plan was developed and discussed with the licensee which includes more frequent monitoring inspection visits to ensure compliance with this compliance plan and Title 22 Regulations for 2 years. Licensee was provided the link below for resources and guidance to improve facility operations: https://www.cdss.ca.gov/inforesources/community-care/resource-guide-for-providers. This report was reviewed with Chief Operations Officer, Matt Stevenson, Scott Carlson, Senior Vice President of Operations, Jenn Sato, Senior Vice President of Operations, Patricia Murphy, Regional Director of Operations, Safoora Ahmed, Vice President of Memory Care and Programming, Kevin Wrigley, Vice President of Regulatory, and Chris Schuster, Executive Director, and Joel Goldman, Partner at Hanson Bridgett LLP. A copy of the report was provided.the state’s words, verbatim · CDSS document, May 13, 2026

Type of visit: Required - 1 Year

On 2/26/2026, Licensing Program Analyst(LPA) John Calandra arrived at the facility to complete the 1-year required inspection. LPA Calandra was greeted by Kelly Phillips, Health Services Director and explained the purpose of the visit. LPA toured the physical plant. This is a five story building with 180 bedrooms, 180 bathrooms, common spaces, a backyard, and memory care unit. No accessible bodies of water or hazards were observed. LPA toured random rooms. All rooms had the required furniture and sufficient lighting. All bathrooms had anti-skid flooring and floor mats and grab bars. The facility's fire alarm and Carbon Monoxide detectors were observed to be functioning properly and according to the facility's maintenance director were directly connected to the San Francisco Fire Department. The facility's fire extinguishers were observed to be fully charged and last checked on 10/27/2025. The facility had the required 7 days of non perishables and 2 days of perishables on site. No food was expired. The facility's first aid kit was observed to have the required items. All sharp objects, soap, detergent, and poisons were observed to be locked and in-accessible to persons in care. LPA reviewed 6 staff and 5 resident files during yesterday's visit. No deficiencies cited during today's visit. An exit interview was conducted and a copy of the report provided to the facility representative.the state’s words, verbatim · CDSS document, Feb 26, 2026

Type of visit: Required - 1 Year

On 2/25/2026, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct the Annual 1-year required inspection. LPA Calandra was greeted by Kelly Phillips, Health Services Director and explained the purpose of the visit. LPA Calandra toured the physical plant. This is a five story building that consists of 180 bedrooms and 180 bathrooms. All bedrooms had sufficient lighting and all the required items. No accessible bodies of water or hazards were observed. Bathrooms were observed to have the required grab bars and anti-skid mats. The backyard was clear from obstructions. The facility was maintained at a comfortable temperature of 70 degrees Fahrenheit. A review of Centrally stored medications indicated that medications for most residents were properly labeled with instructions on dosage and times of day and matched the Centrally Stored Medication records(CSMR) kept at the facility. During the inspection, LPA observed that the facility had a physician's order for R1's medication but the physical medication was not present in the Centrally Stored Medications Room. LPA reviewed 5 resident files and 6 staff files. All were observed to be complete. The Annual Inspection will be completed at a later date. Deficiencies are cited under the California Code of Regulations. Failure to correct the deficiencies by the POC due date may result in Civil Penalties. An exit interview was conducted. A copy of this report along with Appeal Rights were provided.the state’s words, verbatim · CDSS document, Feb 25, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(5) · Plan of correction due date: Feb 26, 2026

87465(h)(5): The following requirements shall apply to medications which are centrally stored: (5)Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by: Based on observation, Licensee had a physician's order for R1's medication but did not have the physical medication for R1, which is an immediate health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 25, 2026

Plan of correction: Licensee will contact pharmacy and place order for Medicaiton. Licensee will notify family and physician that resident has not been getting medication. Licensee will also be conducting a medication audit, will have an additional full time staff member in charge of medications going forward and will do another training.

The state marks this report as 7 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff are not taking steps to prevent the spread of a communicable disease. Staff did not safeguard resident personal belongings. Staff did not ensure that resident was attending medical appointments.

On 2/18/2026, Licensing Program Analyst(LPA) John Calandra arrived at the facility to deliver conclusionary findings for this complaint. LPA Calandra was greeted by Kelly Phillips, Health Services Director and Chris Schuster, Executive Director/Administrator and explained the purpose of the visit. Complaint alleged that staff did not take steps to prevent the spread of a communicable disease as they allowed R1 to room with their roomate while still testing positive for COVID-19. Based on interviews of staff, the facility followed their infection policies by notifying the local Public Health Department after learning R1 had tested positive. In addition, R1's physician was contacted per facility policy and R1's roomate was not moved out of their room per the facility's infection control policies. Unsubstantiated Complaint alleged that clothing, shoes, and bedding have gone missing from R1's room and have not been returned or misplaced by the Licensee. Based on interviews of the Administrator and staff, the facility made reasonable efforts to safeguard R1's property by providing a secured room and by labeling R1's articles of clothing and other items. In addition, the Licensee found/returned or in some cases, replaced any missing items or provided reimbursement per their theft and loss policy. Complaint alleged that resident had missed several medical appointments. Based on interviews of staff, R1's responsible party takes them to medical appointments. In addition, many of R1's appointments take place inside of the facility. On some occasions, R1 has refused to go to their medical appointments and facility staff have talked to R1 about it but R1 has still refused. Although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted. A copy of the report was provided to the facility representatives.the state’s words, verbatim · CDSS document, Feb 18, 2026 · control 14-AS-20250905165459

Type of visit: Case Management - Other

On 1/29/2026, Licensing Program Analyst(LPA) John Calandra, arrived at the facility to follow up on a self-reported incident involving a resident, R1 who was reported to have taken their own life. LPA Calandra was greeted by Kelly Philips, Health Services Director and explained the purpose of the visit. According to the Administrator, Chris Schuster and Kelly Philips, Health Services Director, R1 was found unresponsive in their own room by staff. R1 was reported to be completely independent (did not receive medication assistance or any other types of services) and kept to themselves. On the day of the incident, a member of their Health Services team called 911 who came to the facility and are currently investigating the situation. During the visit, LPA interviewed staff and obtained the following records: staff self-attestations of the event LIC 602: Physician's report Appraisal of Needs and Services LPA requested copies of the following documents by 2/6/2026: Incident Reports submitted regarding R1 R1's care notes No deficiencies were cited during today's visit. An exit interview was conducted. A copy of this report was provided to the facility representative.the state’s words, verbatim · CDSS document, Jan 29, 2026

Type of visit: Case Management - Incident

On 12/23/2025, Licensing Program Analyst(LPA) John Calandra arrived at the facility for the purpose of following up on a complaint received by the Department on 7/11/2025. LPA Calandra was greeted by Chris Schuster, Administrator and explained the purpose of the visit. During the course of the investigation, the Department learned that the facility had admitted R1 who was considered a fall risk but did not create a fall prevention plan to meet R1’s needs. A Type B citation was provided for this deficiency. The Licensee was cited for this deficiency on 10/13/2025. This case management is in regards to the complaint #14-AS-20250711142309. A Plan of Correction has already been provided for this citation. Deficiency cleared during visit. Deficiencies are cited under the California Code of Regulations, Title 22. Failure to correct the deficiencies by the due date may result in civil penalties. An exit interview was conducted. A copy of this report along with Appeal Rights was provided.the state’s words, verbatim · CDSS document, Dec 23, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(d) · Plan of correction due date: Oct 20, 2025

87464(d): Basic Services: A facility need not accept a particular resident..if a facility chooses to accept...the facility shall be responsible for meeting the resident's needs... This requirement is not met as evidenced by: Based on interviews, the Licensee accepted R1 who was considered a fall risk, but did not have a fall prevention plan in place to meet R1's needs, which is a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 23, 2025

Plan of correction: Licensee will create a fall plan for the resident and document all safety checks.

Type of visit: Case Management - Other

On 12/23/2025, Licensing Program Analyst(LPA) John Calandra arrived at the facility to deliver an Amended report originally delivered on 10/19/2025. LPA Calandra was greeted by Chris Schuster, Executive Director/Administrator and explained the purpose of the visit. Licensee surrendered the original copy of the report. No deficiencies cited during today’s visit. An exit interview was conducted. A copy of this report was provided to the facility representative.the state’s words, verbatim · CDSS document, Dec 23, 2025

Allegation investigated: Staff did not administer medications to a resident in care.

On 12/18/2025, Licensing Program Analyst(LPA) John Calandra arrived at the facility to deliver conclusionary findings for this complaint received by the Department on 10/14/2025. LPA Calandra was greeted by Chris Schuster, Administrator and explained the purpose of the visit. Complaint alleged that staff did not administer medications to a resident in care. When R1 moved into the facility, a list of medications was provided to the Licensee. Based on interviews and record review, the Licensee only received two of the three pages of the Centrally Stored Medication records from R1's provider. Thus, the medications were not provided to R1. Although the above 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. An exit interview was conducted. This report was reviewed with facility representative and a copy provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Dec 18, 2025 · control 14-AS-20251014100803

Type of visit: Case Management - Incident

On 12/18/2025, Licensing Program Analyst(LPA) John Calandra made an unannounced visit in regards to a complaint received by the Department on 10/14/2025. LPA Calandra was greeted by Chris Schuster, Administrator and explained the purpose of the visit. During the course of the investigation, the Department learned that R1's responsible party provided medications that the Licensee did not have a physician's order for. The Licensee placed said medications in their Centrally Stored Medications room but did not log the medications nor contact the physician of R1 to ask about the medications. Residents in all residential care facilities for the elderly be accorded safe, healthful and comfortable accommodations, furnishings and equipment per Title 22. When R1 was not provided the medications, R1 was not accorded safe, healthful, and comfortable accommodations. A Type B citation was provided for this deficiency. Deficiencies are cited under the California Code of Regulations, Title 22. Failure to correct said deficiencies result in Civil Penalties. An exit interview was conducted. A copy of this report along with Appeal Rights.the state’s words, verbatim · CDSS document, Dec 18, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Dec 31, 2025

87468.2(a)(4): Additional Personal Rights of Residents in Privately Operated Residential Care Facilities: Residents shall have the following personal rights: To care, supervision, and services that meet their individual needs... This requirement is not met as evidenced by: Based on interviews the Licensee did not ensure R1 was provided care, supervision, and services that met their individual needs when the Licensee did not contact R1's primary care physician upon receipt of their medications, which is a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 18, 2025

Plan of correction: Licensee has already conducted several trainings with staff. Licensee will submit a plan in writing detailing all trainings that have been completed, who attended said trainings and how they plan to ensure the deficiency will not occur again in the future.

Allegation investigated: Lack of supervision resulted in resident falling and sustaining injuries. Staff are not reporting incidents involving residents as necessary.

*****This is an amended version of the original report dated 10/13/2025, as a result of supervisory review******* On 10/13/2025, Licensing Program Analyst(LPA) John Calandra arrived at the facility to deliver conclusionary findings for this complaint. LPA Calandra was greeted by Chris Schuster, Administrator and Executive Director and explained the purpose of the visit. Complaint alleged that lack of supervision resulted in R1 falling and sustaining injuries. Since their admission in 2024, R1 fell over ten times at the facility resulting in R1 sustaining serious injuries such as fracture of a body part. Based on interviews, R1’s health had declined more significantly over the last few months. While a fall risk assessment had been completed by staff, R1 did not have a fall prevention plan in place. Based on interviews, staff were to conduct safety checks every 2 to 3 hours but no documentation of checks being conducted could be provided. Substantiated Complaint also alleged that facility staff are not reporting incidents involving residents as necessary. Based on interview and document review, there were several occasions in which R1 fell but the Licensee did not complete a written report within 7 days of the occurrence of the event for 9 out of the 10 falls. Based on information reported by and obtained from facility staff and witnesses, these allegation is substantiated. The preponderance of evidence standard has been met. Deficiencies are cited under the California Code of Regulations, Title 22. Failure to correct the deficiencies by the due date may result in civil penalties. An immediate civil penalty of $500.00 was issued and a copy of the LIC 421IM was given to Chris Schuster, Administrator/Executive Director. At the time of the complaint inspection on 12/23/2025, licensee was informed that the incident is currently under review and a future civil penalty may apply based on Health and Safety Code § 1569.49. Exit interview conducted. A copy of the report issued. Appeal Rights provided. Facility representative signature on this report acknowledges receipt of the Appeal Rights, found on page two of LIC 421IM.the state’s words, verbatim · CDSS document, Oct 13, 2025 · control 14-AS-20250711142309

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Oct 20, 2025

87466: Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes... and that appropriate assistance is provided when such observation reveals unmet needs. This requirement was not met as evidenced by: Based on interviews, the Licensee did not ensure that R1 was provided with appropriate assistance after the Licensee observed them falling on multiple occasions which is an immediate health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 13, 2025

Plan of correction: Licensee will reevaluate the resident and put an appropriate plan in place. Licensee will also conduct additional training and send list of attendees and content of training to the Department by the POC due date. Licensee will also ensure all safety checks are documented.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Oct 20, 2025

87211(a)(1): Reporting Requirements: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events. This requirement is not met as evidenced by: Based on document review, Licensee did not submit a written report to the Department for each fall occurrence of R1, which is a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 13, 2025

Plan of correction: Licensee will send an incident report for any fall. Licensee will work with Regional Director of Clinical Services and will ensure that all staff understand Licensing regulations and facility's internal policies.

Type of visit: Case Management - Other

On 10/13/2025, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct a Case Management visit in regards to a Change in Management request. LPA Calandra was greeted by Kelly Phillips, Health Services Director and explained the purpose of the visit. LPA Calandra requested the following documents by 10/17/2025: - Updated LIC 200 with new administrator name. -LIC 501-Personnel Report -LIC 503-Health Screening Report -Copy of photo ID -Copy of current Administrator Certificate -Copy of First Aid/CPR Certificate -Fingerprint clearance. -Updated LIC 610E Emergency Disaster Plan -Updated LIC 9282 Infection Control Plan -If you signed the hospice waiver request, please submit new request for new administrator. -Board Resolution Letter(Letter appointing the new administrator from the Board) No deficiencies were cited during today's visit. An exit interview was conducted. This report was reviewed with facility representative and a copy provided.the state’s words, verbatim · CDSS document, Oct 13, 2025

Allegation investigated: Licensee is not ensuring that resident has hot water while in care

On 7/1/2025, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of delivering complaint investigation findings and was greeted by Executive Director, Fili Igafo. LPA toured the facility, interviewed facility staff, outside parties and made observations during the course of the investigation. Complaint alleges licensee is not ensuring that resident has hot water while in care. Upon tour of multiple resident bedrooms across several residential floors; LPA and staff tested water temperature dispensed from bathroom showers and found water temperature to be within approrpriate range. In addition, statement from reporting party provided contradicting information towards the allegation. Due to a lack of corroborating evidence the allegation is found to be unsubstantiated. Nothe state’s words, verbatim · CDSS document, Jul 1, 2025 · control 14-AS-20250602135433

Type of visit: Case Management - Annual Continuation

On 3/26/2025, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of continuing the Annual Required - 1 Year Inspection and was greeted by Executive Director, Fili Igafo. LPA completed a tour of the remaining portions of the facility including additional resident apartments, kitchen and food storage area and facility vehicles. LPA continued on tour of the facility with staff and found all exits and doorways to be free from obstruction. Exit stairwells were all equipped with evacuation chairs and elevators were found to have current inspection permits. Resident bedrooms were found to be in a clean and comfortable condition with housekeeping and laundry services provided on a weekly basis. All resident rooms are equipped with signaling system that directs to staff pagers. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations, with food stored in the kitchen, sufficient for residents in care. Food supply is replenished multiple times per week or as needed and stored properly. Facility provides a wide variety of meal preferences and preparation while also ensuring proper dietary restrictions are followed. LPA observed the facility shuttle to be equipped with a fire extinguisher which was fully charged. The facility offers a wide variety of activities for the assisted living and memory care units and encourage residents to participate regularly. LPA observed residents participating in group exercise and discussion, individual physical therapy, and attending musical guest performances throughout the visit. Residents were observed to be very engaged in the community and found to have a positive and personable relationship with staff and Executive Director. No deficiencies cited during today's visit.the state’s words, verbatim · CDSS document, Mar 26, 2025

Type of visit: Required - 1 Year

On 2/25/2025, Licensing Program Analysts (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by Regional Operations Specialist, Alan Fox. The facility currently provides care for 164 residents, 10 of which are receiving hospice services along with a designated memory care unit. LPA continued with a tour of the facility with staff, facility found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, memory care unit and resident common spaces were inspected. Fire Extinguishers located throughout the inspected portions of the building were found to be charged. Smoke and carbon monoxide detectors and fire safety systems are interconnected. Cleaning supplies and other toxins are safely stored in locked closets throughout the facility, and housekeeping/maintenance rooms all of which were secured upon inspection. There was a supply of hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings and bedding items. Residents in the memory care unit that were awake during the inspection were observed interacting with staff, fellow residents and visitors in the common areas, or in their bedrooms resting. The facility encourages regular family visits and utilizes a wide variety of activities with LPA observing staff engaging continuously with residents, offering activities based on individualized preferences and abilities. LPA observed group karaoke and movies presented to residents along with a variety of activity supplies available. LPA found that staff and resident engagement is well practiced with activity calendars developed on a monthly basis. Residents were found to have a positive and personable relationship with staff. Continued onto LIC809-C LPA conducted a sample file review for 10 residents and found all items to be on file. LPA's found that residents Needs & Service Plans and Medical Assessments were up to date. Upon a spot check of 10 staff files, LPA found that caregiver staff have current first aid and annual training, health screenings and TB results on file. Lastly, a spot check of medications was conducted and found that all medication counts and records are in order. LPA will be conducting an annual continuation to further inspect remaining resident living quarters, kitchen and food supply and facility transportation. Executive Director, Fili Igafo's Administrator Certificate 7003332740 is currently pending for renewal but has been received by the department with application received 11/18/2024. LPA requested the following documents be sent to CCL by COB 3/11/2025: LIC 308 Designated Facility Responsibility LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan Liability Insurance No deficiencies cited during the visit.the state’s words, verbatim · CDSS document, Feb 25, 2025

Type of visit: Case Management - Incident

On 12/27/2024, Licensing Program Analyst, Tobola arrived unannounced for the purpose of conducting a case management to follow up on several incidents reported by the facility. Incident dated 11/11/2024 indicated a resident, (R1) to have boarded onto a bus while they were on an outing with a 1:1 private caregiver from an outside agency. While under private caregiver's supervision, R1 had left on the bus alone and returned to their private family home. R1 was safely returned to the facility with R1's updated services reflecting a new 1:1 care agency. A second incident occurring 11/12/2024, indicated that a resident, (R2) had been observed by staff walking on foot and leaving the property. Staff attempted but were unable to redirect R2, with R2 continuing out into the public. R2 had voluntarily returned back to the facility by bus within approximately 2 hours with no injuries or changes of condition. Upon review of R2's records, LPA found that R2 medical records have contradicting information on whether R2 can leave unassisted or not. Medical assessment indicates R2 is able to leave the facility unassisted but not dated. LPA is requesting for the facility to update R2 medical assessment and provide a copy. Since the incident, the facility has increase R2, level of care, including 1:1 care companion. The facility was found have responded appropriately to prevent further incidents. A third incident dated 11/10/2024, indicated that a resident, (R3) had been provided a shower by two caregivers. R3 was in a shower chair with a seat harness attached. Caregiver staff reported to management that R3 was observed sliding off the shower chair. Caregiver staff responded by slowly assisting/guiding R3 to the floor for reassessment. R3 had sustained a fracture to the femur but the facility was unable to interview the resident and determine any additional findings for how the fracture occurred. LPA was informed that R3 had utilized a hoyer lift and had a history of general weakness in the knees. The facility responded immediately with R3 sent out on medical emergency and returned the same evening. LPA found that the facility responded appropriately to the incident with no determination on how the injury was sustained. Lastly, LPA and Acting Administrator, Fili Igafo discussed a previous request for a hospice waiver increase. At the time of visit, the facility is within the current hospice waiver capacity and will no longer need an increased hospice waiver or exceptions at this time. No deficiencies cited during today's visit.the state’s words, verbatim · CDSS document, Dec 27, 2024

Allegation investigated: Facility staff are locking residents in their bedrooms Facility staff are not conducting planned activities with residents

On 11/7/2024, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of delivering complaint investigation findings and was greeted by Administrator, Fili Igafo. LPA toured the facility, interviewed staff, gathered facility records and made observations during the course of the investigation. Complaint alleges facility staff are locking residents in their bedrooms. Based upon tours of the facility memory care unit and observations, LPA found that all resident door handles have been modified and requires a key to open from the outside of the bedroom. Complaint further alleges that residents are not able to exit due to diagnoses of dementia. Residents however are able to freely leave the bedroom as all bedroom doorknobs do not have a locking mechanism or any devices preventing residents exiting from inside the bedroom (photos taken). LPA attempted to contact Local San Francisco Fire Inspector for additional details on fire safety requirements but was unable to conduct interview due to no response or returned contact. Due to a lack of corroborating evidence the allegation is found to be unsubstantiated. Continued onto LIC9099-C Unsubstantiated Complaint alleges facility staff are not conducting planned activities with residents. Based upon tours of the facility memory care unit LPA observed residents engaging with staff and outside parties with various activities throughout the day. The activities observed included group exercise, pet therapy, music and yoga through multiple visits in accordance with facility activity calendar. Due to a lack of corroborating evidence, the allegation is found to be unsubstantiated. A finding that the complaint allegations, facility staff are locking residents in their bedrooms & facility staff are not conducting planned activities with residents are unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Nov 7, 2024 · control 14-AS-20240814165101

Type of visit: Case Management - Other

On 11/7/2024, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of closing an investigation conducted by the Department in regard to a self reported unusual incident report dated 4/21/2024. The incident report indicates that on 4/18/2024, staff checked on resident (R1) in their apartment, finding R1 laying on the floor with a plastic bag over (their) head, tied around (their) neck. Staff determined the resident was unresponsive. According to incident report, the hospice agency was called and then hospice instructed to call 911 due to the “unnatural death.” The Department has reviewed and gathered relevant records including facility incident reports, resident R1 needs & service plans, physician’s reports, daily chart notes and medical records related to this incident and determined the following: On 3/28/2024, R1 had indicated to their family and the facility a refusal to eat and additionally made statements of ending R1’s own life. R1’s family and the facility contacted 911 with R1 sent out for medical attention due to physical pain and suicidal statements. An updated care assessment for R1 had been completed on 3/25/2024 prior to this incident. No further care assessments were conducted after 3/28/2024 when R1 was sent out for medical assessment, or after 3/29/2024 upon R1’s return to the facility. There are no indications of increased status checks or assigning one-on-one care for R1 for preventative measures documented. Based upon the Department’s conducted interview and information gathered with the Health Service Director (S1) the following is indicated: S1 is a Licensed Vocational Nurse (LVN) at Ivy Park. S1 duties are to oversee the care staff, conduct assessments for new and existing residents, review resident’s medication, administer medication to residents, deal with family and resident concerns, and train care staff and medical techs. S1 continues, residents are checked on every one to two hours unless the service plans states that there should be more checks. Staff will not check on a resident if the resident does not want to be checked on. Residents are given an alert pendent when they first arrive at the facility. Continued onto LIC809-C The pendent allows the resident to call for help when they need it. There are no logs kept when a resident is checked on. When a new resident is admitted to the facility, S1 will conduct an assessment on the resident before they move in. The assessment is done to see what assistance the resident may need with their Activities of Daily Living (ADL) and their mental health status. S1 updates the service plans when a resident has a change in condition. The Department interview with S1 continued regarding R1 level of care and supervision and observations leading to R1’s death. This revealed that S1 was aware of the repeated suicidal statements made by R1 to staff and the hospice nurse. Although S1 admitted they were aware of the change of condition, S1 failed to complete a reappraisal for change in resident’s status and the need for increase status checks of R1 after repeated suicidal statements. S1 additionally indicated that residents are to receive one-on-one after indicating suicidal ideations. S1 however failed to ensure one-on-one care was provided for R1. Lastly, S1 admitted that they should have been more “on top of” R1s situation, provided more frequent checks, and provided R1 additional resources. Based upon the Department’s conducted interview and information gathered with the Executive Director (S2) the following is indicated: S2’s duties are to oversee the facility, manage the lead staff, work on the facilities’ financial, sign off on payroll for the facility, work with the facility nursing director, and approve and review incident reports. S2 continues, residents are checked on one time per shift. Caregivers can check on residents anytime during their shift as long as the resident is checked on before the end of the shift. Residents can refuse to be checked on. Residents are also given an alert pendant that they can press if they need assistance at any point in time when they have an emergency. No log is kept when a resident is checked on. When the facility accepts a new resident, an assessment completed by Health Service Director (S1) to determine the resident needs before they move into the facility. S1 also conducts a mental health evaluation to see if the resident requires memory care. The assessment is also performed to see if the resident is a fit for assisted living or memory care. S1 then reports to the care team what the new resident’s needs and level of care. After the initial assessment is performed, a second assessment is completed two weeks later to see how the resident is adjusting to the facility and determine any updated needs. A reassessment is performed every six months or when a resident has a change of condition. The facility considers a change of condition when there is a change in the resident’s baseline behavior or mental health status. Continued onto LIC899-C The Department interview with S2 continued regarding R1 level of care and supervision and observations leading to R1’s death. S2 indicated that when a resident states that they are going to harm themselves, Health Service Director, S1 is notified, S1 speaks with the resident, and notifies the resident’s Primary Care Provider and responsible party. S1 is to remove any harmful objects from the resident’s apartment if necessary and update the resident’s service plan to more frequent status checks every two hours. S1 is also responsible for making a recommendation to the family for the resident to receive one-on-one care paid for by the family. The facility can provide the one-on-one care to the family at an additional cost or with the option to pay for an outside company to and provide the additional care. If a resident has suicidal thoughts or attempts, they will be placed on increased status checks and will be checked on every two hours. The facility staff will also encourage the resident to socialize in the community more with the other residents. S2 was not aware of R1 having any mental health concerns when R1 arrived at Ivy Park. However, S2 was aware that R1 was exhibiting suicidal ideations with R1’s family calling 911 in March 2024 due to R1 stating that they were going to stop eating and made statement of wanting to commit suicide. The facility responded by sending R1 to the hospital for an evaluation. S2 stated that they required S1 to update R1’s needs and services plan upon return. Additionally, S2 addressed to S1 and R1’s family that R1 needed to be placed on hospice. S2 stated that R1’s care plan was updated to have assistance with his ADL’s but was not certain if S1 updated R1’s plan to have increased checks. Based upon document review it was found that R1 had bend sent out to the hospital for evaluation on 3/28/2024 and returned 3/29/2024. Record review found that the most updated needs and service plan was dated 3/25/2024 and input on 3/27/2024, prior to R1 initially being sent out for hospital. Interview continues indicating S2 was first aware of R1’s suicidal statement in March 2024. R1 was provided room checks every two hours before R1 made suicidal statements. Room checks were not updated and with R1 still provided room checks every two hours after R1 made his suicidal statements. S2 discussed one-on-one care with R1’s family but R1 never received the one-on-one care. On 04/18/2024, S2 indicated that Health Service Director (S1) and hospice nurse discussed R1 again stating that they wanted to commit suicide. The hospice nurse removed a pair of scissors from R1’s room and S2 held a follow up discussion with S1 regarding the one-on-one care for R1. S1 addressed to S2 that they did not follow back up with the family regarding the one-on-one care. On the same date 4/18/2024, R1 was found in their bedroom deceased. Continued onto LIC809-C S2 stated that after R1 made initial statements about taking their own life, the facility should have updated R1’s needs and services plan to include increased checks. S2 was not aware of why the increased checks were not implemented. S2 admitted that R1’s death could have been prevented if R1 was given one-on-one care sooner and was provided more supervision. The Department additionally conducted interviews with several caregiving staff but found information and statements to be inconsistent with investigation. An immediate civil penalty is being assessed today in the amount of $500 for a violation that resulted in the sickness or injury of a resident in care. Additional Civil Penalty pending review per H&S Code Section 1569.49. Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and the Health and Safety Code. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Appeal Rights Given.the state’s words, verbatim · CDSS document, Nov 7, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Nov 8, 2024

87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities - (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This was not met as evidence by: Based upon interviews with Health Service Director and Executive Director and review of resident (R1) records it was found that the facility identified a need for R1’s change in level of care due to suicidal ideations. However, Executive Director and Health Service Director failed to provide care and services to meet R1’s needs, resulting in severe injury/death by means of suicide. This is an immediate health and safety & personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 7, 2024

Plan of correction: Licensee/Administrator failed to ensure the care and supervision under resident personal rights was provided to resident (R1), resulting in the severe injury/death of R1 by means of suicide. Licensee agrees to submit proof of training for staff on personal rights and suicide training by POC date 11/8/2024. In addition, continuous training is implemented for suicide prevention and personal rights of residents. Lastly, S1 is no longer working for the facility. IMMEDIATE CIVIL PENALTY OF $500 WAS ASSESSED FOR VIOLATION RESULTING IN SICKNESS OR INJURY TO A RESIDENT IN CARE.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87466 · Plan of correction due date: Nov 8, 2024

87466 Observation of the Resident: Licensee shall ensure that residents are...observed for changes in physical, mental, emotional & social functioning & that appropriate assistance is provided when such observation reveals unmet needs. When changes...or deterioration of mental ability or a physical health condition are observed, licensee shall ensure that such changes are documented & brought to the attention of the resident's physician & responsible person, if any.." This was not met as evidence by: Based upon interviews with Health Service Director (S1) and Executive Director (S2) and review of resident’s (R1) records, it was found that the facility observed and were aware of R1’s suicidal statements and change of condition, indicated on 3/28/2024 and on 4/18/2024, but failed to ensure appropriate changes to R1’s level of care was initiated or documented, leading to severe injury/death of R1. This is an immediate health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 7, 2024

Plan of correction: Licensee/Administrator failed to ensure resident (R1) observed changes of condition and suicidal statements were properly addressed through updated level of care and documentation. Licensee agrees to submit proof of training for staff on personal rights and suicide training by POC date 11/8/2024. In addition, continuous training is implemented for suicide prevention and personal rights of residents. Lastly, S1 is no longer working for the facility.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87463(a) · Plan of correction due date: Nov 8, 2024

87463(a) Reappraisals – (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to..” This was not met as evidence by: Based upon interviews with Health Service Director (S1) and Executive Director (S2) and review of resident (R1) documents, it was found that the S1 identified a need for R1’s change in level of care due to suicidal ideations and hospital visit on 3/28/2024. However, Health Service Director (S1) failed to develop and document an updated care plan to address R1’s suicidal ideations and increased supervision, leading to the severe injury/death of R1. This is an immediate health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 7, 2024

Plan of correction: Licensee/Administrator failed to ensure proper development and documentation of an updated care plan/appraisal was completed for resident (R1), after staff (S1) was aware of R1's suicidal statements and need for medical attention on 3/28/2024 regarding the matter. Staff S1 is no longer working for the facility. Licensee has implemented multiple regional staff now serving as Resident Service Director ensuring compliance for appraisals and reappraisals. Deficiency cleared.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87405(a) · Plan of correction due date: Nov 8, 2024

This is an amendment to original report date of 11/7/2024 to identify corrected regulation section: 87405(a) The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. This was not met as evidence by: Based upon interviews with Health Service Director (S1) and Executive Director (S2) and review of resident (R1) documents it was found that S2 failed to ensure frequent checks on R1 was done as recommended, that R1's appraisal was updated including suicidal ideations with updated staffing plan, and that R1 is performing their duties, which is ultimately the responsibility of S2.the state’s words, verbatim · CDSS document, Nov 7, 2024

Plan of correction: Licensee had previously submitted LIC9098 Corrections Form indicating regulation review and agreed to conduct continuous training on resident personal rights and suicide prevention. Deficiency cleared at the time of visit.

Type of visit: Case Management - Incident

On 8/28/2024, Licensing Program Analyst, Tobola arrived unannounced for the purpose of conducting a case management to follow up on a facility self-reported incident and was greeted by Executive Director, Fili Igafo. The incident occurring on 6/7/2024, involved morning staff observing a table that was blocking resident’s (R1) bedroom door. The incident was reported to CCLD by the facility and confirmed based on the report and staff interviews with LPA Calandra, that overnight caregiver staff (S1) intentionally placed table in front of R1’s door to prevent R1 from wandering. LPA Calandra previously gathered information on the incident and spoke with Executive Director on corrective actions. LPA Tobola was informed that the facility had conducted an internal investigation and terminated staff (S1). Due to resident R1's door being obstructed intentionally by staff, the facility has failed to ensure residents room door were unobstructed and violated the personal rights of resident R1. Deficiency cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.the state’s words, verbatim · CDSS document, Aug 28, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(6) · Plan of correction due date: Sep 4, 2024

Personal Rights of Residents in All Facilities - ..to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department. This was not met as evidence by: Based on a review of facility Incident Report and interviews with LPA Calandra and Executive Director, it was found that staff (S1) was found and admitted to have placed a table in front of resident (R1) bedroom door, preventing R1 from leaving. This is a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 28, 2024

Plan of correction: Administrator has taken corrective action and terminated staff (S1). Deficiency cleared at the time of visit.

Allegation investigated: Staff did not provide adequate supervision resulting in resident falling. Staff did not respond to resident's call button in a timely manner.

On August 9, 2024, Licensing Program Analysts(LPAs) John Calandra and Dominic Tobola, arrived at the facility at 9:20 AM to deliver findings for a complaint opened on March 12, 2024. LPAs Calandra and Tobola, were greeted by Tam Nguyen, Maintenance Director and explained the puprose of the visit. Fili Igafo, Executive Director arrived later during the visit. Regarding the allegation, that staff did not provide adequate supervision resulting in resident falling, the department interviewed multiple staff. Through these interviews, it was found that staff had knowledge of other staff who were preoccupied with other activities during working hours and not attending to resident’s needs. Furthermore, the LPAs learned that the there is a lapse in communication amongst staff resulting in staff, not being able to provide adequate care and supervision to persons in care. Therefore, the preponderance of evidence standard has been met and this allegation is SUBSTANTIATED. Substantiated Regarding the allegation, that staff did not respond to resident’s call button in a timely manner, the Department found through a review of the call button response log that on several occasions, facility staff have taken up to a total of 289 minutes to respond to call buttons. Furthermore, the LPAs learned that within the last 2 weeks, there have been a total of 16 residents who waited more than 30 minutes for assistance. Regarding this allegation, the preponderance of evidence has been met, and the allegation is SUBSTANTIATED. The Department has investigated the above allegations of a possible violation of a resident’s personal rights. Based on the investigation, the preponderance of evidence standard has been met, therefore the above allegations are determined to be SUBSTANTIATED. The deficiencies cited on the following pages are in violation of the California Code of Regulations, Title 22, Division 6, Chapter 8, Article 7: Personnel Requirements-General. An exit interview was conducted. This report was reviewed with Fili Igafo, Executive Director and a copy of the report along with Appeal Rights were left at the facility. Regarding the allegation, that the resident was left on the floor for an extended period of time, LPAs interviewed staff and asked but were not able to procure a copy of the call button response times. Due to a lack of evidence, this allegation is UNSUBSTANTIATED. The department has investigated the above allegations that staff did not observe resident’s change of health conditions or reassess resident’s care plan. The allegations are UNSUBSTANTIATED meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted. This report was reviewed with Fili Igafo, Executive Director and a copy of the report left at the facility.the state’s words, verbatim · CDSS document, Aug 9, 2024 · control 14-AS-20240305161257

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Aug 10, 2024

87468.1 Personal Rights of Residents in All Facilities..(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:..(2) To be accorded safe,.. This requirement is not met as evidenced by record review and interview of Executive Director, which revealed that 16 out of 137 clients waited in some cases more than 289 minutes for care, which is an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 9, 2024

Plan of correction: Licensee/Administrator to submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Aug 23, 2024

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 observation and interview of staff, which showed that multiple facility staff are not competent to provide the services necessary to meet resident needs.the state’s words, verbatim · CDSS document, Aug 9, 2024

Plan of correction: Licensee/Administrator to submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date.

Allegation investigated: Staff did not ensure emergency services were contacted in a timely manner

On May 14, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility at 9:00 AM to conduct an unnanounced Complaint Investigation. The purpose of the visit was to open a complaint received on May 9, 2024 and deliver conclusionary findings. LPA Calandra was greeted by Executive Director, Fili Igafo, and explained the purpose of the visit. LPA Calandra gathered relevant information to the above allegation, interviewed staff and collected documents. Regarding the allegation of a violation of resident’s personal right to medical services, it was found that there was at least one time that staff did not contact emergency personnel in a timely manner. Residents have medical and dental needs, and the Licensee shall provide assistance in meeting those necessary medical and dental needs. Staff have failed to do this based on information gathered. Substantiated The Department has investigated the complaint allegation that staff did not contact emergency personnel in a timely manner. We have found that the complaint allegation is substantiated. Based on the investigation, the preponderance of evidence standard has been met. The deficiency cited on the following page is in violation of the California Code of Regulations, Title 22, Division 6, Chapter 8: This report is provided and reviewed with Executive Director, Fili Igafo, and a copy of this report must be made available for public review upon request. Appeal rights discussed and provided.the state’s words, verbatim · CDSS document, May 14, 2024 · control 14-AS-20240509102757

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(2) · Plan of correction due date: May 15, 2024

87465(a)(2): 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: (2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service. This requirement has not been met as evidenced by: This requirement has not been met as evidenced by facility staff did not call 911 immediately for R1 but instead waited to tell S1 when S1 started their shift. 911 was alerted approximately 2 hours after R1 was found unresponsive. Medical personnel were not contacted in a timely manner.the state’s words, verbatim · CDSS document, May 14, 2024

Plan of correction: Facility shall develop a plan of correction (POC) to ensure compliance with Sec.87465(a)(2). Facility will develop a plan to ensure that residents' medical and dental needs are met without delay. That plan will be received by CCLD to address deficiency.

Allegation investigated: Staff did not ensure they have records for new residents Facility has a pest infestation

On May 14, 2024, Licensing Program Analyst (LPA) John Calandra conducted a conclusionary complaint investigation at the facility and met with Fili Igafo, Executive Director. The purpose of the visit was to deliver conclusionary findings to the initial complaint investigation on January 4, 2024. LPA gathered information relevant to the above complaint allegation and conducted interviews with staff and residents. In regard to the allegation that the facility has a pest infestation, it was determined that while the facility had pests in the past, they had not had a pest infestation and have retained pest control services. Based on this information, the finding of this allegation is determined to be unsubstantiated. Regarding the allegation that staff did not ensure they have records for new residents, the LPA reviewed records and interviewed staff. It was determined that the facility did in fact have records for new residents. Unsubstantiated The Department has investigated the complaint allegation of a personal rights violation and resident reassessment. We have found that the complaint allegations are unfounded, meaning that the allegations are false, could not have happened and/or are without a reasonable basis. This report is provided and reviewed with the Executive Director, Fili Igafo and a copy of this report must be made available for public review upon request. The Department has investigated the above complaint allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are determined to be unsubstantiated. This report is provided and reviewed with facility representative, and a copy of this report must be made available for public review upon request.the state’s words, verbatim · CDSS document, May 14, 2024 · control 14-AS-20231226123813

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

On May 14, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility to deliver an Amended complaint investigation report from January 4, 2024. LPA Calandra was greeted by Fili Igafo, Executive Director and explained the purpose of the visit. The report was Amended due to new information being discovered through the course of the investigation LPA Calandra obtained the facility's copy of the report from January 4, 2024. This report was reviewed with Executive Director, Fili Igafo and a copy of the report left at the facility.the state’s words, verbatim · CDSS document, May 14, 2024

Type of visit: Case Management - Health Checks

On April 23, 2024 at 9:30 AM, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct an unannounced Case Management-Health and Safety check in regards to an incident report received by the department on April 22, 2024 regarding the death of a resident. LPA Calandra was greeted by Alan Fox, Regional Operations Specialist and explained the purpose of the visit. LPA Calandra requested and received the following documents: -Resident's LIC 602-Physician's report -Annual Needs and Service Plan or Care Plan -Admissions Agreement - Progress notes - Resident's Medication Records - Doctor's orders - Resident Record - Hospice Notes No deficiencies were cited during today's visit. This report was reviewed with Alan Fox, Regional Operations Specialist and a copy of the report left at the facility.the state’s words, verbatim · CDSS document, Apr 23, 2024

Type of visit: Case Management - Annual Continuation

On February 15, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility at 9:00 AM to continue the Annual 1-year required inspection. LPA Calandra met with Michelle Herman and explained the purpose of his visit. Faimafili Igafo, Executive Director arrived later during the visit. LPA Calandra reviewed 5 resident records. All were observed to be complete. LPA Calandra interviewed 3 residents and 3 staff. No deficiencies were cited during today's visit. The report was reviewed with Faimafili Igafo, Executive Director and a copy of the report left at the facility.the state’s words, verbatim · CDSS document, Feb 15, 2024

Allegation investigated: -Staff did not ensure they have records for new residents -Facility has a pest infestation -Staff did not keep residents personal information confidential

This report was Amended due to new information being found through the course of the investigation. Report was reviewed with Fili Igafo, Executive Director and a copy of the report left at the facility. On January 4, 2024, Licensing Program Analyst(LPA), John Calandra and Licensing Program Manager(LPM), Cara Smith arrived at the facility at 9:30 am to open a complaint with four allegations. LPA Calandra and LPM Smith met with Ella Frick, Executive Director and asked for the following documents: -Roster with apartment numbers and move-in dates. -Resident files -Pest Control Inspection Reports LPA Calandra and LPM Smith took a tour of the facility's common spaces including dining rooms and a cafe on the first, second, and fourth floors which were observed to be clean and orderly. LPA and LPM reviewed four resident records. Assessments were up to date. Newly admitted residents records were also observed to be complete. LPA and LPM collected resident documents and pest control inspection reports. LPA Calandra and LPM Smith also interviewed Arturo Balancas, Senior Maintenance Director. No concerns were noted. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 4, 2024 · control 14-AS-20231226123813

Allegation investigated: -Staff did not administer resident's medication as prescribed -Staff do not answer resident's call button in a timely manner

On December 15, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the findings for the above allegations. LPA met with Executive Director, Ella Frick and explained the purpose of the visit. Regarding the allegation, staff did not administer resident's medication as prescribed, according to the reporting party, Resident 1 (R1) should be receiving 200mgs of a prescribed medication daily. In addition, reporting party indicated that the prescribed medication comes in 100mg tablets so R1 should be receiving two tablets a day in the morning, the facility’s instructions were to provide one tablet a day. During the visit, LPA interviewed staff, observed R1's medications, reviewed R1's physician's orders and MAR. Based on documentation reviewed, LPA observed a discrepancy between the physician's order, the MAR system being used by the facility, and the prescription bottle that was given by the pharmacy. According to the physician's order and the MAR system, R1 was prescribed 200mgs tablet of Lamotrigine and instructions were to take 1 tablet by mouth daily per physician's order. However, based on observations, R1's Lamotrigine prescription bottle contained 100mg tablets and instructions were to take 2 tablets (200mg) by mouth daily. The facility observed the discrepancy, however failed to contact the physician and/or the pharmacy for clarification. On 11/30/23, LPA conducted a complaint visit and observed R1's Lamotrigine prescription bottle. R1 started his/her prescription bottle of Lamotrigine (100mg/quantity 180 tablets) on 8/23/2023. During the visit on 11/30/2023, LPA observed 8 tablets in the bottle. Based on MAR review, R1 has never refused his/her Lamotrigine prescription. In addition, based on staff interviewed, R1 should have started a new prescription bottle on 11/22/2023. Furthermore, based on staff interviewed, it was observed that a staff member accidentally gave R1 one tablet of Lamotrigine, however caught the issue and provided R1 another tablet. (CONT. TO 9099C) Substantiated Regarding the allegation, staff do not answer resident's call button in a timely manner, according to the reporting party, within the last six months, there has been issues with staff not responding to call buttons. In addition, according to the reporting party, R1 pressed his/her call button for help and was left waiting for two hours. During the investigation, LPA reviewed R1’s call records and observed on 11/20/2023, R1 pressed his/her call button at 7:44am, however a staff did not respond to R1’s call button request until 8:52am, 67 minutes after pressing the call button. In addition, on 9/26/23, R1 pressed his/her call button at 7:43am and a staff member did not respond to the call pendant till 8:38am, 55 minutes after pressing the call pendant. In addition to reviewing R1’s record, additional resident records were reviewed. During additional record review, LPA observed Resident 2 (R2) pressed his/her call button on 9/8/23 at 6:46am and staff responded 120 minutes later at 8:52am. Furthermore, R2 pressed his/her call button on 9/7/23 at 11:13am and staff did not respond till 12:33am, 80 minutes after R2 pressed his/her button for assistance. Based on interviews, observations and record review during the investigation, the preponderance of evidence standard has been met. Therefore, the above allegations were determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. §1569.312 Basic services(a)- A civil penalty of $1,000 is assessed on 12/15/2023 for a repeat violation within 12 months. This violation was cited on 7/5/2023. Report was discussed with Executive Director, Ella Frick and a copy is provided with appeal rights. A copy of civil penalty is provided.the state’s words, verbatim · CDSS document, Dec 15, 2023 · control 14-AS-20231128101756

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Dec 22, 2023

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 provide for assistance in obtaining such care, by compliance with the following: (4)The licensee shall assist residents with self-administered medications as needed. Violation of this regulation is not met as evidenced by: Based on interviews conducted, a staff member observed another staff member accidentally give R1 one tablet instead of two tablets, however caught the issue and provided R1 with another tablet. Based on record review, there was a discrepancy between a discrepancy between the physician's order and the MAR system being used by the facility, and the prescription bottle that was given by the pharmacy as the MAR system and the physician’s order indicated to provide R1 with one 200mg tablet of Lamotrigine daily, however the prescription bottle from the pharmacy indicated to provide R1 with two 100mg of Lamotrigine tablets daily. Nevertheless, the facility failed to provide R1 with his/her Lamotrigine prescription as prescribed by R1’s physician and follow up with R1's physician and/or the pharmacy for clarificationthe state’s words, verbatim · CDSS document, Dec 15, 2023

Plan of correction: Licensee/Administrator to provide in-service training with staff and med-techs to ensure that residents are receiving prescription medication as prescribed by the physician. In addition, training shall include facility protocols if there is a discrepancy with physician's orders and the presciption bottle given by the pharmacy

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(a) · Plan of correction due date: Dec 16, 2023

§1569.312 Basic services requirements..Every facility required to be licensed under this chapter shall provide at least the following basic services:..(a) Care and supervision as defined in Section 1569.2. Violation of this regulation is not met as evidenced by: Based on record reviewed, on 11/20/23, R1 pressed his/her call button and a staff member responded 67 minutes later. In addition, on 9/26/23, staff did not respond to R1’s call button in a timely manner as a staff responded to R1’s call 55 minutes after he/she pressed her button. Furthermore, additional record reviewed showed that it took staff 80 minutes on 9/7/23 and 120 minutes on 9/8/23 to respond to R2’s call button.the state’s words, verbatim · CDSS document, Dec 15, 2023

Plan of correction: Licensee/Administrator to conduct an in-service training with staff to turn off call buttons and call pendants after responding to residents calls. Training shall also include the importance of responding to residents in a timely manner A civil penalty of $1,000 is assessed on 12/15/2023 for a repeat violation within 12 months. This violation was cited on 7/5/23