Sutro Heights Corporation

On 05/20/2026 Licensing Program Analyst (LPA) Yi Sam Jian conducted an unannounced complaint inspection to deliver findings regarding the complaint allegations received. LPA met with staff, Shirley Aguado, LPA explained the purpose of the visit. Administrator, Laymer Pamintuan, was contacted over the phone and grant permission to staff, Lea Pantangco, to sign all required documents. Regarding the allegation that staff inappropriately gave resident alcohol, the Department conducted interviews and reviewed records. There was insufficient corroborating documentation and witness statements to determine whether the alleged incident occurred. Although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove whether the allegations did or did not occur, therefore the above allegations are UNSUBSTANTIATED. Report is reviewed and a copy of this report is left at the facility. UnsubstantiatedRead the full finding— CDSS inspection report, May 20, 2026 · control 14-AS-20260227114134

Based on observations by medical professional and review of medication records, this allegation is substantiated. The preponderance of evidence standard has been met. Client #1 was prescribed Cephalexin on 8/8/23 but facility failed to obtain the antibiotic medication because the client did not pick it up. Staff did not make arrangements to pick up or have antibiotic delivered until 7 days later. In addition, Olodaterol/tiotropium inhaler was not refilled, as staff was observed giving client the inhalation device without the medication cartridge installed. Deficiency of the California Code of REgulations, Title 22 is cited on a following page. SubstantiatedRead the full finding— CDSS inspection report, July 25, 2024 · control 14-AS-20230817153442

Based on observations made on 10/2/23 during initial complaint visit, this allegation is substantiated. The preponderance of evidence standard has been met. In backyard, a mattress covered with a ripped mattress cover was observed on top of a patio table and chairs, a plush blanket was draped over a hedge, two wheelchairs were stored under stairs, and numerous empty cardboard boxes were scattered. In addition, boxes, filled plastic bags, tables and overgrowth of plants obstructed the ground level passageway leading from street to backyard. See Facility Evaluation Report of 10/2/23 for Type B deficiency cited. Front room on ground floor was created by construction of wall in bedroom. Wall has since been removed after citation issued on 10/2/23; see Facility Evaluation Report. The small front room formed by the wall had no window. Deficiency of the California Code of Regulations, Title 22 is cited on a following page. SubstantiatedRead the full finding— CDSS inspection report, July 25, 2024 · control 14-AS-20230922090634

Based on LPA Jeung's observations on 9/13/23--as well as information from witnesses--these allegations are substantiated. The preponderance of evidence standard has been met. During facility inspection on 9/13/23, emergency call system was not installed in 3 out of 5 client rooms on ground level. This included the room where former client #1 was residing in room #7. On 9/1/23, client #1 was alleged to have fallen at 2am and called out for staff assistance, as there was no emergency call button. Client waited for over an hour until male staff responded and helped client to get up from the floor. ****Type A Deficiency citation was issued on 9/13/23. See Facility Evaluation Report***** As noted on Facility Evaluation Report on 9/13/23, there is no client file maintained for client #2, who shares second floor room #3 with client #1. Client #2 was admitted on 9/1/23. Continued on next page. SubstantiatedRead the full finding— CDSS inspection report, July 18, 2024 · control 14-AS-20230908153602

On July 5, 2023 Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20230414140716. LPA met with manager, Oscar Madrigal and explained the purpose to today's visit. Regarding to allegation of - facility staff do not ensure that resident's room is ventilated, the reporting party stated that that resident #1 (R1) was transferred to a room without ventilation. As part of the investigation, LPA interviewed R1, facility staff, and former assistant administrator. During the initial complaint visit, LPA observed staff was providing a sponage bath to R1 in the room with the door closed and afterwards, LPA observed the room to be stuffy. LPA interviewed R1 who stated that the room is unventilated when staff failed to open the door after they are done with providing care. SubstantiatedRead the full finding— CDSS inspection report, July 5, 2023 · control 14-AS-20230414140716

On 4/20/2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20230203085150. LPA met with manager, Oscar Madrigal and explained the purpose to today's visit. Regarding to the allegation of facility staff not maintaining resident's hygiene, the reporting party stated that resident #1 (R1) was not showered in 20 days. As part of the investigation, LPA interviewed R1, other residents, facility staff and reviewed records. According to R1, R1 was not showered for a long time but R1 was provided with a bed bath 2-3 times per week. According to resident #2 (R2), R2 was supposed to get a shower at least once a week but R2 has only gotten one in 8 weeks but R2 was provided with a bed bath almost daily. According to resident #3 (R3), R3 did not remember when facility staff provided him/her a shower but R3 was provided with a bed bath a few times a week and R3 preferred having showers every week. Based on the facility's showeRead the full finding— CDSS inspection report, April 20, 2023 · control 14-AS-20230203085150

On 2/8/2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20221025152849. LPA met with manager, Oscar Madrigal and explained the purpose to today's visit. Regarding to allegation of- resident left in soiled diaper for an extended amount of time, there is no additional information forthcoming from the reporting party. However, during the initial reporting, the reporting party stated that during a visit, resident #1 (R1) was in soiled clothing and the reporting party had to change R1. . The administrator denied the allegation and stated that staff documents on a log whenever care is provided to R1 such as turning and repositioning, providing incontinent care, changing and cleaning R1, etc. and the log is placed in R1's room. During the initial 10-day visit on 11/3/2022, LPA observed R1 to be cleaned, appeared to be calm and comfortable. In addition, LPA observed a log on R1's bedside table with documentation by staRead the full finding— CDSS inspection report, February 8, 2023 · control 14-AS-20221025152849

On 2/8/2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20221026144655. LPA met with manager, Oscar and explained the purpose to today's visit. Regarding to allegation of - staff do not answer residents' call bells in a timely manner, there is no additional details forthcoming from the reporting party, however, during the initial reporting, the reporting party stated that sometimes it takes staff ten minutes to answer call bell due to staffing challenges. As part of the investigation, LPA interviewed the administrator who denied the allegation and stated that the facility is having adequate staffing to meet resident's needs. LPA interviewed 5 residents and all of them reported that facility staff are responding to their calls timely, and sometimes it takes a littler longer because they are helping other residents but overall, their needs are being met. Based on observation, and interviews during the course of tRead the full finding— CDSS inspection report, February 8, 2023 · control 14-AS-20221026144655