Bellara Senior Living

Type of visit: Case Management - Health Checks

On this day, July 22, 2026, Licensing Program Analyst (LPA) Delmundo conducted a health and safety inspection as a result of the Department receiving a Priority 1 complaint (Complaint Control # 15-AS-20260721112430). LPA met with Executive Director (ED) Jeff Sumabat and informed the reason for visit. LPA also met with Sr. Generations Program Director (GPD) Joy Quilet. During review of residents' (R1 and R2) records, LPA observed After Visit Summaries and Physician Communications indicating these residents have fall incidents. R1 had 5 fall incidents from 6/04/26 to 7/20/26, of which 4 of these incidents had passed 7 days and facility did not submit nor LPA received incident reports. R2 had multiple fall incidents from 5/10/26 to 7/17/26, of which 7 had also passed 7 days and facility also did not submit incident reports. LPA also observed these residents Care Plans not updated nor reassessment completed to reflect current care needs. Staff (S1) confirmed no incident reports submitted and that Care Plan not updated. LPA toured the Memory Care Unit with Joy Quilet. LPA inspected the following including but not limited to common areas, courtyard, dining and activity areas, servery/kitchenette, toilets and ensuite bathrooms. LPA observed the laundry room locked and medication room attended by a med-tech. LPA randomly selected 7 residents' apartments for inspection including the ensuite bathrooms. .....continued on 809C LPA observed the following during inspection: -at 2:20 pm, shaver in one of the residents' apartments. -at 2:40 pm, unlocked wound solution, Desitin rash ointment, foot cream in another resident's apartment and wound cleanser in the ensuite bathroom. Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. A $250.00 civil penalty is assessed for section # 87309(a) for repeat violation within 12 month period. Failure to submit proof of corrections by plan of correction due dates may result in additional civil penalties. Deficiencies, plan and proof of corrections and civil penalty were discussed with the Executive Director. Exit interview conducted. Appeal Rights, LIC421FC Civil Penalty Assessment and copy of this report provided.the state’s words, verbatim · CDSS document, Jul 22, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Jul 23, 2026

87309 Storage Space and Access (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to resident are in locked storage.... -This requirement is not met as evidenced by: -Based on observation, the licensee did not comply with the section above in the following unlocked in Memory Care apartments which posed an immediate risks to persons in care: razor, wound solution and cleanser; foot cream; rash ointmentthe state’s words, verbatim · CDSS document, Jul 22, 2026

Plan of correction: Staff removed and locked the items. In addition, Executive Director to in-service the staff and submit copy of training topics with attendees signatures by 7/23/26. A $250.00 civil penalty is assessed.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87463(b) · Plan of correction due date: Jul 23, 2026

87463 Reappraisals (b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of the Resident.. .....and to keep the appraisal accurate -This requirement is not met as evidenced by: -Based on records review and interview, the licensee did not comply with the section above in not doing reassessments and/or updating the Care Plan for R1 and R2 which posed an immediate risks to the health, safety and/or personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Jul 22, 2026

Plan of correction: Executive Director to have the Care Plan updated and submit copies by 7/23/26.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Aug 5, 2026

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports ...(1) 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 specified... (D) Any incident which threatens the welfare, safety or health of any resident...... -This requirement is not met as evidenced by: -Based on records review and interview, the licensee did not comply with the section above in not submitting incident reports.the state’s words, verbatim · CDSS document, Jul 22, 2026

Plan of correction: Executive Director to do the following and submit proof by 8/05/26: 1. Submit incident reports. 2. In-service the staff and ensure reports are submitted within Regulations time frame.

Allegation investigated: Facility failed to issue appropriate refund.

On this day, June 10, 2026, at 10:55 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings for the above allegation and close the complaint. LPA met with Resident Care Director (RSD) Karren Melad and informed the reason for visit. LPA later met with Executive Director Jeff Sumabat. It was alleged that the facility failed to issue appropriate refund to resident, R1. During the course of investigation, LPA reviewed R1’s record and obtained copies of the following documents: Admission Agreement; LIC601 Identification and Emergency Contact Information; Authorization Agreement for Direct Payment (ACH); payment records; refund check of $6,368.57 dated March 6, 2026. LPA conducted interviews. ....continued on 9099C Unsubstantiated The Executive Director (ED) stated that Bellara has concessions that if a resident move-in 12/31/25, the month rent will only be $99.00 on the first month and the community fee is only $2,500.00 which is only 50% of the regular $5,000.00 community fee, and R1's moved-in on the record is 12/31/25. The concession of $99.00 on the first month is for 1/01/26 to 1/31/26. S1 confirmed Bellara’s concession. S1 stated that R1 had put a check mark on ACH Authorization of 1 month current and 1 month future rent and that there was an error in Bellara’s billing that R1 was charge full for community fee and full month rent for January 2026. S1 further stated a refund check has been generated dated March 6, 2026 but since R1 should be getting more than the amount on the check, she called and informed R1 on 3/06/26. S1 also stated she was looking at the correct amount that should be refunded and that the refund check with the correct amount should be ready in a week. She never heard from R1 after 3/06/26. On 5/01/26, ED informed LPA that the refund check was hand delivered to R1 on 5/01/26. RP informed LPA of the receipt of the check. Based on information gathered, the allegation in unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that a violation occurred. No deficiency cited. The Executive Director has to leave and stated Karren Melad will sign and receive this report. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 10, 2026 · control 15-AS-20260416134918

Allegation investigated: Staff did not safeguard resident's personal belongings.

On this day, July 10, 2026, at 10:55 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the investigation of the above allegation and close the complaint. LPA met with Resident Care Director (RSD) Karren Melad and informed the reason for visit. LPA later met with Executive Director Jeff Sumabat. It was reported that resident (R1) went to bed on 1/14/26 with gold chain and bracelet on and in the morning of 1/15/26, they were gone. R1’s family hired 1:1 caregivers for R1 during the day and when R1's 1:1 caregiver (W1) arrived that morning, W1 noticed R1 was not wearing the jewelry anymore. ....continued on 9099C Unsubstantiated During the course of investigation, LPA obtained copies of resident roster and staff schedule. LPA reviewed residents' records and obtained copies of including but not limited to LIC601 Identification and Emergency Contact Information, LIC602A Physician's Report and LIC621 Client/Resident Personal Property and Valuables. LPA conducted interviews and received from ED copy of incident reported to Hayward Police Department (HPD). LPA also obtained copy of report from HPD. LPA interviewed the following: resident’s (R1) family member (FM1) on 3/30/26 and 4/01/26; staff (ED) on 4/01/26 and 4/22/26; staff (S2) on 4/22/26; staff (S4) on 6/02/26; staff (S3) on 6/16/26; staff (S1) on 4/01/26, 4/22/26 and 7/10/26; staff (S5, S6 and S7) on 7/10/26; residents (R4, R5, R6, R7 and R8) on 7/10/26; resident's family member (FM2) on 7/10/26. FM1 stated W1 reported that R1 was wearing the jewelry when R1 went to bed on 1/14/26 and were gone when W1 came in the morning on 1/15/26. ED stated that he reported the alleged theft to HPD. S1 stated when the items were reported missing, they searched R1’s apartment and didn’t find them. One of the staff interviewed stated observing R1 wearing bracelet but not the necklace because every time this staff provide administration of medications to R1, R1 was wearing closed neck top. Three of the staff confirmed they were assigned to R1 and observed R1 wore jewelry but denied taking them. One of these staff who put R1 to bed on 1/14/26 after W1 left for the day stated observing R1 wearing only the call pendant but not the jewelry. S6 stated not seeing R1's jewelry and denied taking belongings of any residents. S7 stated no resident reported any missing item to this staff. LPA made multiple phone calls to R1’s 1:1 caregiver (W1) on different dates but W1 did not respond nor return LPA’s call. LPA was unable to interview R1 as R1 was not in the facility when LPA conducted the initial investigation on 4/01/26 and no longer in the facility when LPA conducted subsequent investigation on 4/22/26. .....continued on 9099C Two of the 5 residents stated they haven't lost anything since they moved-in, while 1 of the 5 stated she lost jelwery but may have lost them in the previous home before she moved-in. Another resident stated they lost jewelry and reported it was missing to the maintenance staff but there's no maintenance staff by the name provided by this resident. This resident stated having memory issue. One of the 5 residents stated they lost a particular item but this resident's family member (FM2) stated packing this resident's belonging when resident moved-out from other facility and move them to this facility but can not confirm whether or not the alleged missing item was brought in during move-in. Review of the residents' LIC621s showed no items listed. Based on information gathered during the course of investigation and LPA unable to obtain information from R1 and W1 and no items listed on LIC621s, the allegation is unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that a violation occurred. No deficiency cited. The Executive Director has to leave and stated Karren Melad will sign and receive this report. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 10, 2026 · control 15-AS-20260326120524

Type of visit: Case Management - Deficiencies

On this day, April 1, 2026, while at the facility investigating a complaint (Control # 15-AS-20260326120524) and upon conducting interviews and record review, Licensing Program Analyst (LPA) Delmundo learned that the resident's 1:1 is not fingerprinted. LPA also learned that the facility did not submit incident report and SOC341 for the alleged financial abuse that occurred on January 2026. Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. A $500.00 civil penalty is assessed for deficiency section # 87355(e)(2) and will continue until corrected. Failure to submit proof of correction by plan of correction due date for the other deficiency may result in additional civil penalty. Deficiencies, civil penalty, and plan and proof of corrections were discussed with ED. Exit interview conducted. Appeal Rights, LIC421IM Civil Penalty Assessment, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Apr 1, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)2) · Plan of correction due date: Apr 2, 2026

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Obtain a California clearance or a criminal record exemption as required by the Department -This requirement is not met as evidenced by: -Based on interviews and record review, the licensee did not comply with the section above in resident's 1:1 caregiver not fingerprinted which poses an immediate risks to persons in care.the state’s words, verbatim · CDSS document, Apr 1, 2026

Plan of correction: Administrator not to have the individual work until fingerprinted and associated. Proof to be submitted by 4/02/26. A $500.00 civil penalty is assessed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1) · Plan of correction due date: Apr 15, 2026

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and.......... -This requirement is not met as evidenced by: -Based on interviews and record review, the licensee did not comply with the section above in not submitting incident report and SOC341 which pose a potential personal rights risks to person in care.the state’s words, verbatim · CDSS document, Apr 1, 2026

Plan of correction: Executive Director to submit report by 4/15/26.

Allegation investigated: Licensee does not ensure that facility is kept in good repair.

On this day, 3/3/26 at 12:00 pm, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to investigate the above allegation and to deliver findings. LPA met with Executive Director (ED) Jeff Sumabat and informed the reason for the visit. It was alleged that the Licensee does not ensure that the facility is kept in good repair. On 1/30/2026, LPA K. Nguyen observed that the door in the memory care unit on the second floor is not working properly. LPA tested the delayed egress door above the elevator and inside the memory care unit and observed that the delayed egress door does not open after 15 seconds. On 1/30/26, during an interview with S2, S2 stated, “That door does not open without the keypad code, and when held for 15 second nothing happened”. S1 stated "the 15-second hold was never installed on the door". Report continue on LIC 9099c... Substantiated Based on the information obtained, the preponderance of evidence is met; therefore, the allegation is substantiated. Deficiency is cited from Title 22 California Code of Regulations and listed on 9099D. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in civil penalty. Deficiency and plan and proof of correction were discussed with ED. Exit interview conducted. Appeal Rights and a copy of this report provided. LPA Interviews with 16 residents did not reveal any instances in which their freedom of movement was restricted inappropriately. 16 out of 16 Residents stated they were able to move freely within the facility and access common areas consistent with their individual care plans. Allegation: Licensee does not ensure that residents are provided a healthful environment while in care - Unsubstantiated It was alleged that the licensee does not ensure that residents are provided a healthy environment while in care. During the investigation, LPA conducted interviews with 16 residents, 10 staff, reviewed facility records, and observed a display case with alcohol. Interviews with 11 residents did not indicate concerns regarding alcohol served at the facility, safety, or overall healthfulness of the environment. Resident 1 through Resident 11 stated, “Every Thursday, the facility has happy hours that offer us alcohol; however, facility staff never tried to sell any alcohol. R1 through R11 stated, “The facility offered alcohol to us; however, they based their decision on our medical records, and those who cannot drink were not offered.” S1, S2, and S3 stated, “We don’t ever charge for that; it was just part of our beverages that we offered”. LPA reviewed facility admission agreements; there was no indication of alcohol charges in the admission agreement. Allegation: Licensee does not ensure that the facility is kept in a sanitary condition – Unsubstantiated It was alleged that the licensee does not ensure that the facility is kept in a sanitary condition. Observations made by the LPA on 1/30/26 and 3/3/26 did not reveal unsanitary conditions, including accumulation of trash, odors, pests, or other conditions that would pose health risk to residents. LPA toured a random section of the random Memory Care (MC) apartment (APT) and Assisted Living (AL) apartments. LPA toured the MC and AL apartment, including but not limited to APT: 201, 202, 215, 225, 217, 222, 225, 505, 506, 502, 501, 316, and 133. All APTs are clean and sanitary. There is no odor in any of the apartments. Report continued on LIC 9099c1 LPA conducted 16 random selections of residents. 16 out of 16 residents interviewed did not report concerns regarding sanitation or cleanliness of the facility. LPA conducted 10 Staff interview and 10 out of 10 stated that routine cleaning schedules and sanitation practices are in place and followed to maintain a clean environment. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 3, 2026 · control 15-AS-20260128154841

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Mar 17, 2026

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidence by: Based on observation and interview, licensee did not comply with the section cited above by having inoperable delayed egress door which poses a potential health and safety risk to the residents in care.the state’s words, verbatim · CDSS document, Mar 3, 2026

Plan of correction: Facility has agreed to submit proof that all delayed egress doors will be in operating condition by POC date.

Allegation investigated: Staff did not ensure resident's informaiton is kept confidential.

On this day, 12/24/25, at 11:20 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegation. LPA met with Executive Director (ED) Jeff Sumabat and informed the reason for visit. It was alleged that the Ombudsman Program received two folders in the mail from the facility containing documentation related to resident (R1). The Reporting Party (RP) also indicated that at the time the materials were received, the Ombudsman Program had not had any contact with R1 and was therefore unable to verify whether R1 had provided consent for the release of the information. During the course of investigation, LPA obtained copies of staff schedule and conducted interviews. ....continued on 9099C Substantiated LPA interviewed the Ombudsman (W1) who confirmed they received an SOC341 along with copy of a 30-day notice, R1's financial ledger, and a bill associated with the R1's account. W1 also stated they have not obtain permission from R1 to release the documents to them. LPA interviewed the staff (ED, S2 and S3) and confirmed those documents were mailed out to Ombudsman. Based on information obtained, the preponderance of evidence is met, therefore, the allegation is substantiated. Deficiency is cited from Title 22 California Code of Regulations and listed on 9099D. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in civil penalty. Deficiency and plan and proof of correction were discussed with ED. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided. W1 stated that another Ombudsman came to the facility on 12/19/25 and ED was out. W1 stated there was no designated staff in ED's absence. S1 confirmed that he was the MOD on the said date and that Ombudsman (W2) came over and asked for R1's financial documents, however, only S4, ED and corporate have access to residents' financial records. S1 further stated he sent email that same day to W2 regarding the conversation that transpired between him and W2 and included ED and S4 on the email, however, the email didn't go through. Copy of the email confirmed S1's statement. S1 also stated that any information pertaining to residents' care, there's always staff present to provide information. LPA interviewed ED who confirmed he was not at the facility on the said date, however, the manager on duty (MOD) that day was S1 and MOD's support was S3. ED further stated that on his days off, there's always MOD assigned. ED stated that only him, S4 and corporate have access to the residents' financial records. S3 confirmed she was at the facility on 12/19/25. S3 and S2 both stated there's always MOD scheduled when ED is out. Based on information gathered and review of LIC500, the allegation in unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiency cited. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Dec 24, 2025 · control 15-AS-20251219152836

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.269(a)(3) · Plan of correction due date: Jan 7, 2026

§1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (3) To confidential treatment of their records and personal information and to approve their release, except as authorized by law. -This requirement is not met as evidenced by: -Based on interviews, the licensee did not comply with the section above in providing R1's documents containing confidential information to Ombudsman Program when consent for release from R1 has not been obtained which posed a potential personal rights risk to person in care.the state’s words, verbatim · CDSS document, Dec 24, 2025

Plan of correction: Executive Director stated and agreed to in-service the staff. Proof to be submitted by 1/07/26.

Allegation investigated: Staff does not ensure resident has adequate lighting in the bathroom.

On this day, November 17, 2025, at 10:10 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegation. LPA met with Director of Facilty Operations (DFO) Arturo 'Art' Blancas and informed the reason for visit. The reporting party (RP) stated the facility has motion sensor light switches in the bathrooms which cause light to go out and bathroom to go dark. This is especially dangerous when showering because the resident had to get out with wet feet to try and get light back on. The RP also stated the facility informed them that they would not change the light switches to be normal on/off and was told to put a plugged in lamp but the shower is still dark with shower curtain closed. LPA obtained copies of resident roster and email communication with family member and conducted interview. ......continued on 9099C Unsubstantiated LPA interviewed the DFO who stated that the issue is not ignored. DFO indicated he had communicated with a family member and recommended the plug-in light as an alternative as he continues to research for a potential light switch that will be more convenient. DFO further stated that he had a conversation with the building contractor sometime last week. Although the building contractor informed him that it is okay to purchase the light switch to replace the motion sensor light, but because it is electrical, he would like to have the contractor do the work. On this same day, DFO called the contractor to schedule the replacement of the bathroom lights. Based on information gathered, the allegation is unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiency cited. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Nov 17, 2025 · control 15-AS-20251113082718

Type of visit: Required - 1 Year

On this day, November 12, 2025, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with Executive Director (ED) Jeff Sumabat, and informed the reason for visit. LPA also met with Director of Facilty Operations (DFO) Arturo 'Art' Blancas. LPA toured the facility with ED and DFO. Facility is a 5 story building. LPA inspected the following: common areas; kitchen; dining area; salon, barber shop and wellness center on the first floor; courtyard on the 2nd floor; electrical, housekeeping and trash room on the 4th floor. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Walk-in freezer and refrigerator temperatures were at -7 and 37 degrees Fahrenheit respectively; temperatures were checked by kitchen staff and recorded daily, and records showed temperatures were within Regulations range. Facility has emergency food suppies. LPA randomly selected 10 resident apartment units for inspection - 2 on each floors. Medication room was observed locked. Hot water temperature in one of the resident's apartment units was tested and measured at 120 degrees Fahrenheit. Facility has evacuation chairs on stairwells. Facility conducts disaster drills and records showed last conducted September 14, 2025 LPA reviewed 5 staff and 7 resident's files, and interviewed 3 residents. Doctor's orders were inspected. Facility does not handle resident's cash resources/P&I. .....continued on 809C LPA observed the following: -at 11:00 am, cleaning agent in unlocked cabinet on the 2nd floor in the servery area. -resident's (R1) bed has bed rails but no doctor's order on file. The following updated/current documents to be submitted by November 26, 2025: 1. LIC308 Designation of Facility Responsibility 2. LIC500 Personnel Report 3. LIC610E Emergency Disaster Plan (9 pages) 4. LIC9182 Infection Control Plan 5. $3M Liability Insurance certificate Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates and any repeat violation within 12 month period may result in civil penalty. Deficiencies and plan and proof of corrections were discussed with ED. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Nov 12, 2025

Allegation investigated: Staff did not report incident to residents' family.

On this day, 10/29/25, Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegation. LPA met with Executive Director (ED) Jeff Sumabat and informed the reason for visit. It was alleged that the incident between 2 residents (R1 and R2) was not reported to the residents' family. The reporting party stated the residents' family has been trying to contact staff to inquire about the incident that happened on 10/18/25 and no one has called the family back. LPA reviewed residents records and obtained copies of LIC601 Identification and Emergency Contact information and LIC602A Physician's Reports, staff schedule and residents roster. LPA interviewed residents' family member (FM1), staff (S1 and S2), ED, R1 and R2. .......continued on 9099C. Substantiated S1 stated that staff, S2, reported to S1 that R1 went down to the front desk on the day of the incident. S1 further stated it was R2's family member, FM2, who sent her text message about the incident and S1 assumed FM2 reported the incident to FM1. S1 stated FM2 indicated that R1 and R2 had a fight because R2's cpap was broken. S1 stated she went to R1 and R2's apartment on 10/19/25 and observed R2's arm has bruise and that R2 reported R1 grabbed R2. ED stated the incident happened after ED was gone for the day and that S1 and S2 reported the incident to the ED that night. FM1 stated that R1 and R2 had an incident on 10/18/25, of which R2 punched R1 in the ribs. R2 admitted the physical altercation to FM1 but the incident was not reported by the facility to FM1. FM1 further stated that on the day of incident, R1 went down to the front desk and called FM1 to report the incident. R1 was crying and distraught. R1 stated having altercation with R2 and that R1 grabbed R2 in the arm. R2 stated pushing R1 during the altercation. Review of email communications revealed it was FM2 who reached out to ED on 10/19/25 regarding the incident and the email was only responded on 10/21/25. Based on information gathered, the allegation is substantiated. Deficiency is cited from Title 22 California Code of Regulations and listed on 9099D. Failure to submit proof of correction by plan of correction due date and any repeat violation may result in civil penalty. Deficiency and plan and proof of correction were discussed with ED. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided. S2 confirmed the incident that R1 went to the front desk staff. The front desk staff called her, and she along with the care staff, S3, went to R1 and R2's apartment. R2 broke down and admitted to calling R1 out from drinking alcohol which made R1 got out of control. S2 further stated that they facilitated R2 and told R1 to watch tv. R1 and R2 are not on hourly check and S2 only provides passing of medications to R2. S1 confirmed the incident; however, S1 was off on the day it happened. R2 admitted to having an altercation with R1 and that R2 pushed R1 in the ribs. R2 further stated R1 grabbed him in the arm which R1 admitted but R1 does not remember the date it happened. ED stated a personal companion provided by a third party was placed for R1 back in December 2024 until the family discontinued paying the 3rd party. ED further stated that R1 and R2 are not on hourly check which LPA confirmed upon review of Service Plan. Based on all the information gathered, the allegation is unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiency cited. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Oct 29, 2025 · control 15-AS-20251021141652

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(9) · Plan of correction due date: Nov 12, 2025

87468.1 Personal Rights of Residents in All Facilities (a) .......(9) To have communications to the licensee from their representatives answered promptly and appropriately. -This requirement is not met as evidenced by -Based on document review and interviews, the licensee did not comply with the section above in not reporting the incident to the residents' family and not responding timely.the state’s words, verbatim · CDSS document, Oct 29, 2025

Plan of correction: Executive Director will do the following: and submit proof by 11/12/25: 1. In-service the staff. 2. Ensure proper and timely communication with the residents' families are accorded.

Type of visit: Case Management - Deficiencies

While at the facility investigating a complaint (Control # 15-AS-20251021141652) and upon interviews and review of the Department's incident reports for the facility, Licensing Program Analyst (LPA) Delmundo learned that the facility did not report the incident that occurred on 10/18/25 between residents, R1 and R2, to appropriate agencies. Review of R1 records showed R1 has major neuro cognitive disorder, can not leave the facility unassisted, has wandering and sundowning behaviors. Executive Director (ED) Jeff Sumabat stated when R1 and R2 moved-in, a wander guard was issued for R1; however, during interview, LPA observed R1 without wander guard. ED also stated that care conference was conducted with the residents' family and medical provider, however, R1 was resisting care and a personal companion which was placed in December 2024 for R1 was discontinued in March 2025 by the family. LPA learned that service plan was not updated accordingly after the incident happened on 10/18/25. Review of R2's Physician's Report dated 9/10/25 revealed R2 needed assistance with medications including administration of injection and R2's Care Plan was also not updated to reflect the change. Deficiencies cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of corrections by plan of correction due dates and any repeat violation may result in civil penalty. Deficiencies and plan and proof of corrections were discussed with ED. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Oct 29, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(c) · Plan of correction due date: Nov 12, 2025

87211 Reporting Requirements (c)Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours as.. ...required by Welfare and Institutions Code Section 15630(b)(1). -This requirement is not met as evidenced by: -Based on records review and interviews, the licensee did not comply with the section above in not reporting the incident to appropriate agencies.the state’s words, verbatim · CDSS document, Oct 29, 2025

Plan of correction: Executive Director to do the following and submit proof by 11/12/25: 1. Submit LIC624. 2. Submit SOC341 to appropriate agencies. 3. In-service the staff and submit copy of training topic with attendees signatures.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87563(b) · Plan of correction due date: Nov 12, 2025

87463 Reappraisals: (b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of the Resident. -This requirement is not met as evidenced by: -Based on records review and interviews, the licensee did not comply with the section above in not updating R1 and R2's Care/Service Plan to reflect their current care and/or supervision needs.the state’s words, verbatim · CDSS document, Oct 29, 2025

Plan of correction: Executive Director stated the following: 1. Update the Care Plan and discuss with the residents and residents' family. 2. Submit copies of the documents. 3. Ensure Care Plan is implemented/followed. Proof to be submitted by 11/12.25.

Allegation investigated: Staff are not providing adequate food service to resident(s)

On 6/24/2025, at 11:30 AM, Licensing Program Analyst (LPA) James Sampair arrived unannounced to investigate the allegation above. Upon arrival, the LPA informed Executive Director (ED) Jeff Sumabat of the purpose of the visit. The complaint alleges staff are not providing adequate food service to resident(s). The LPA interviewed Witness W1 by telephone. At the facility, the LPA interviewed the ED and nine residents. The data collected from the interviews shows that the staff are providing adequate food service to residents of the facility, which does not confirm the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove it; therefore, the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 24, 2025 · control 15-AS-20250618082702

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs) Jill Clancy-Czuleger and David Doidge conducted an announced Component III Training. Component III was attended by Jeff Sumbat (Executive Director) and Regional Vic President of Operations (VPO ) Zach Butcher. LPA Clancy-Czuleger presented the training via Power Point presentation and had a discussion with the ED and . Exit interview conducted and copy of this report provided at the conclusion of the trainingthe state’s words, verbatim · CDSS document, Oct 16, 2024

Type of visit: Office

COMP II by CAB successfully completed Method: Phone Call at CAB Applicant/administrator participated in COMP II at CAB telephone call with analyst at CAB. Identification of the applicant and administrator was verified by presenting photo ID via phone. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Staff qualifications and responsibilities 3. Applicant and Administrator qualifications 4. Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions 5. Grievances, Complaints, Community resources 6. Physical plant, food service 7. Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of propertythe state’s words, verbatim · CDSS document, Sep 30, 2024