Brookdale Scotts Valley

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced complaint investigation for complaint 26-AS-20260828092528. LPA met with Operations Specialist (OP) Michele Nation. During the visit, LPA observed a deficiency while conducting the inspection. A case management was initiated for the deficienct that was found during the complaint investigation that is not related to the complaint. During the tour LPA inspected 5 resident rooms with Operations Specialist (OP). LPA observed 3 Out of 5 resident rooms to be unsanitary, with dark spots/stains on carpets, mal odors, uncovered trash bins (observed with soiled paper towels with feces), and 1 toilet soiled with feces. These issues were brought to the attention of OP during the inspection. OP removed the trash and flushed the toilet with feces. LPA observed the interior of the toilet to be black (pictures taken on state phone). OP stated residents rooms should be cleaned weekly, and was unable to state why the resident's rooms were not clean. OP stated the maintenance director was not working today, and was unable to provide additional information as to the state of the resident's rooms and how often staff were cleaning the resident's rooms. A deficiency is being cited per California Code of Regulations, Title 22. See LIC809-D. An exit interview was conducted with Operations Specialist (OP) Michele Nation Staff Sam Small RN and a copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 31, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Sep 1, 2026

87303 (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 was not met as evidenced by; Based on observation, 3 out of 5 resident rooms were observed with dark spots/stains on carpets, mal odors, uncovered trash bins (observed with soiled paper towels with feces), and 1 toilet soiled with feces, which poses an immediate health, safety, and personal rights risks to residents in care.the state’s words, verbatim · CDSS document, Aug 31, 2026

Plan of correction: Licensee will submit a Plan of Correction (POC) stating how the facility will ensure residents rooms are clean, safe, sanitary and in good repair at all times for the safety and well-being of residents. Licensee will submit POC to CCLD by POC due date 9/1/2026.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced annual inspection and met with Interim Director Dimple Kamdar. LPA stated the purpose of the visit. Interim Director stated she was conducting meetings with families, and would designate a staff on her behalf. Interim Director designated Maintenance Director (MD) Sheila Gonzalez to accompany LPA for the facility inspection. LPA toured the interior and exterior of the facility with MD to include the kitchen, resident rooms, dining area, hallways, activity areas, and back and front of the facility. All exit and passageways were free and clear of obstruction. LPA toured the kitchen area and observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA observed refrigerator temperature at 40 F and Freezer at -10 F. LPA observed a freezer with food crumbs and spilled liquid inside. MD was advised to have kitchen staff clean the freezer. LPA discussed with MD that all kitchen areas should be kept clean. MD stated understanding. A Technical Assistance was issued, see LIC9102 for more information. LPA observed knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. The facility was equipped with smoke and carbon monoxide detectors. The facility fire system was inspected by a third party vendor on 7/21/2026 and passed inspection. Page 1 of 2 Fire extinguishers were last serviced on 12/9/2025. The facility emergency drill log was reviewed. The facility's last drill was conducted on 7/16/2026. LPA toured 10 random resident bedrooms. 10 resident rooms have a bed, functioning lights, dresser/table, bedding and space for personal belongings. 10 resident bathrooms had hand soap, paper towels, functioning lights, and covered trash bins. LPA measured water temperature in 10 resident bathrooms with a range of 107.4 F to 113.5 F. LPA reviewed 10 resident records. 4 Out of 10 resident records did not contain a Pre-Admission Appraisal. 10 out of 10 resident records did not contain Functional capabilities. A Technical Violation was issued, see LIC9102 for more information. LPA reviewed 10 resident’s Centrally Stored Medication and Destruction Records (CSMDR’s). Medication rooms were observed as locked and inaccessible to residents in care. LPA reviewed 10 staff records. No deficiencies were cited during today's visit per California Code of Regulations Title 22. Technical Violations and a Technical Assistance were issued, see LIC9102 for more information. An exit interview was conducted with Interim Director Dimple Kamdar and a signed copy of this report was provided. Page 2 of 2 END OF REPORTthe state’s words, verbatim · CDSS document, Aug 25, 2026

The state marks this report as 6 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

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

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced Case Management to conduct a Quarterly Visit and met with Executive Director (ED) Alex Baiasu. LPA stated the purpose of the visit. The purpose of the visit is to ensure the facility is adhering to the Facility's Action Plan submitted to Community Care Licensing (CCL) after an Informal Conference meeting held on 8/13/2024. During visit, LPA reviewed staff training on personal rights and proper resident approach, as part of the facility's Action Plan submitted to the Department on 8/20/2024. LPA reviewed documentation of staff training conducted on 4/29/2026, 4/30/2026, 5/25/2026 which included but not limited to topics such as Resident Approach/Resident Rights, Safe Resident Handling, Code of Conduct. ED stated staff are also checking on residents twice during the overnight shift as well. The facility is adhering to the facility's Action Plan for staff training. No deficiencies cited per California Code of Regulations, Title 22. This report was reviewed with Executive Director (ED) Alex Baiasu and a signed copy of this report was providedthe state’s words, verbatim · CDSS document, Jun 29, 2026

Allegation investigated: Staff did not assist resident after a fall

Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to conduct a complaint investigation visit. LPA met with Executive Director (ED) Alex Baiasu. LPA stated the purpose of the visit. On 5/5/2026 the Department received a complaint alleging that a resident "fell on a Tuesday" and was not assisted by facility staff. No additional information was provided regarding this incident. On 5/7/2026 the Department interviewed Executive Director (ED), 5 staff and 10 residents. ED states he is not aware of any residents that have fallen and were not assisted by staff. Page 1 of 2 Unfounded On 5/7/2026 the Department interviewed 6 Staff (S1 to S6). 6 Out of 6 staff stated he/she is not aware of and has not observed staff not assisting a resident who has fallen. On 5/7/2026 the Department interviewed 10 residents (R1 to R10). 10 out of 10 residents stated staff assist him/her when needed. 6 Out of 10 residents stated he/she has fallen, and staff assisted him/her when he/she fell. R4 and R9 stated he/she has observed residents fall at the facility, and facility staff helped the residents who fell. The Department reviewed incident reports submitted from March 2026 to May 2026. There were no reported incidents of staff not assisting residents who had fallen at the facility. The Department also toured the facility and the facility was observed to be clean, safe, sanitary and in good repair. The Department reviewed Training Attendance Forms for facility staff to include but not limited to Fall Assessment (1/9/2026), Activating Emergency Services (1/9/2026), Resident Rights (1/30/2026 and 2/27/2026), Reportable Events (4/10/2026), and All Staff Providing Assistance with ADLs (Activities of Daily Living) to Residents (4/10/2026). The Training Attendance forms are signed and dated by facility staff. This agency has investigated the complaint alleging staff did not assist resident after a fall, we have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with ED Alex Baiasu and a copy of this report was provided. Page 2 of 2 END OF REPORTthe state’s words, verbatim · CDSS document, May 7, 2026 · control 26-AS-20260505155121

Allegation investigated: Staff do not ensure resident's incontinence care needs are being met. Resident fell while in care due to lack of staff supervision.

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced complaint investigation visit to deliver complaint findings. LPA met with Executive Director (ED) Alex Baisu. LPA stated the purpose of the visit. On 11/18/2025 the Department received a complaint with the above allegations On 11/19/2025 the Department interviewed the Reporting Party (RP). RP states a resident, referred to as R1, was left in a soiled brief between 10/01/2025 - 11/18/2025 due to staff not meeting R1’s incontinence needs. RP stated he/she was "not so concerned with R1's incotinence care." R1 did not provided additional information regarding these incidents. Page 1 of 3 Unsubstantiated On 11/19/2025 and 4/20/2026 the Department conducted complaint investigation visits and interviewed 4 Staff (S1 to S4), 4 Residents (R1 to R4) and 1 Witness. 4 Out of 4 staff state he/she is not aware of and has not observed a resident left in a soiled brief. S2 states R1 preferred to change his/her own brief. On 11/19/2025 and 4/20/2026 The Department interviewed 4 Residents (R1 to R4). 3 Out of 4 Residents stated he/she does not require any assistance with toileting. 3 Out of 4 Residents state he/she does not have any issues or concerns with the care he/she is receiving. R1 did not respond to questions due to cognitive impairment. On 11/19/2025 the Department interviewed 1 Witness (W1). W1 states he/she has worked with R1 for approximately six months. W1 states he/she has not observed R1 left in a soiled brief due to staff not attending to residents’ incontinence needs. Review of R1’s physician’s report dated 2/8/2024, R1 is noted to have bladder impairment. R1 is also unable to care for his/her own toileting needs and needs assistance with toileting. Review of R1’s care plan dated 10/22/2025, R1 is noted to not require bathroom assistance, “can manage his/her own bathroom needs at this time.” Review of R1's progress notes from 5/1/2025 to 11/29/2025, there are no noted incidents of R1 being left soiled by facility staff. Resident fell while in care due to lack of staff supervision On 11/19/2025 the Department interviewed the Reporting Party (RP). RP states a resident, referred to as R1, had four falls during between May 2025 to November 2025 due to lack of staff supervision. RP stated the facility informed him/her about these incidents of R1 falling. On 11/19/2025 the Department interviewed 1 Witness (W1). W1 states he/she has worked with R1 for approximately six months. Page 2 of 3 W1 states R1 had four falls during these six months (May 2025 to November 2025). W1 states R1 was checked frequently by facility staff during the time the falls occurred. W1 stated R1 is ambulatory and uses a wheelchair and can self-transfer (to and from the wheelchair). W1 states he/she does not believe R1 fell due to staff neglect. Review of R1’s physician’s report dated 2/8/2024, R1 is noted to have motor impairment/paralysis, walks with a cane.’ R1 is non-ambulatory due to physical condition. Review of R1's progress notes from 5/1/2025 to 11/29/2025, R1 is being checked on by facility staff with noted incidents of R1 falling on 11/14/2025, 10/24/2025, 9/22/2025, and 5/6/2025. R1 was assessed by facility staff, and all responsible parties were notified of the falls. Review of R1’s care plan dated 10/22/2025, for ‘Escort & Mobility’ R1 is noted as “independent going to and from the dining room or community activities, resident has falls in the last twelve months, resident has fallen without apparent harm/injury, resident uses a cane as a mobility aid, resident uses a walker as a mobility aid, resident uses a manual wheelchair as a mobility aid." Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with ED and a copy of this report was provided. Page 3 of 3 END OF REPORTthe state’s words, verbatim · CDSS document, Apr 20, 2026 · control 26-AS-20251118161725

Allegation investigated: Unlawful eviction

Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to deliver complaint findings. LPA met with Executive Director (ED) Alex Baiasu. LPA stated the purpose of the visit. On 2/9/2026 the Department received a complaint with the above allegation. On 2/11/2026 the Department interviewed the Reporting Party (RP). RP states a resident, referred to as R1, is being unlawfully evicted from the facility. RP states R1 is being evicted due to behaviors of stalking of staff on 1/28/2026. RP did not provide additional information regarding these behaviors. Page 1 of 3 Unfounded On 2/18/2026 the Department conducted the initial investigation visit, and interviewed 2 Staff (S1 to S2), and 1 Resident (R1). 2 Out of 2 staff state he/she is aware of an incident between R1 and a staff but did not remember the date of the incident. S2 stated he/she heard R1 make an inappropriate comment about a staff during a resident and staff meeting. S2 did not remember the date of this incident. On 2/18/2026 the Department interviewed R1. R1 states after a recent staff and resident meeting in January 2026, the Executive Director (ED) told him/her that his/hers behavior and statements during this meeting violated facility policies. R1 states he/she 'only smiled' when facility staff were acknowledged during the meeting. R1 states later in the same day, his/her pants fell while in the dinner hall. R1 states his/her pants did not fit correctly. R1 stated three staff were present during this incident and observed R1 with his/her pants down. On 2/19/2026 the Department interviewed 2 Witnesses (W1 to W2). 2 Out of 2 witnesses state he/she is aware of R1 having behaviors and making inappropriate comments to facility staff. W1 states he/she was informed by the ED in late January 2026 about R1’s behaviors. W1 states ED requested W1 to inform R1’s physician. W1 states he/she received an eviction notice for R1 on 2/17/2026. W2 states he/she was informed about R1’s behaviors in February 2026. W2 states that the facility followed proper protocol regarding facility policies and R1 behaviors violated the facility's heath and safety policies. Review of R1’s eviction notice is dated 2/2/2026, and states R1 is being evicted due to ‘failure to comply with the general policies of the Community.” The effective date of termination is 3/3/2026.” R1 is noted to have behaviors on 1/23/2026 and 1/26/2026. The eviction notice states “R1 has failed to follow many of the Community’s policies and procedures which is now disrupting the peaceful lodging of other residents and putting other’s health and safety at risk.” On 4/20/2026 the Department interviewed ED. ED states R1 is still residing at the facility. Page 2 of 3 This Department has investigated the above allegation. Based on the investigation, documents reviewed, and interviews conducted, the Department found that the above allegation is UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. No deficiencies cited during today’s complaint investigation visit, per California Code of Regulations Title 22. An exit interview was conducted with ED and a copy of the report was provided to ED. Page 3 of 3 END OF REPORTthe state’s words, verbatim · CDSS document, Apr 20, 2026 · control 26-AS-20260209105606

Allegation investigated: Staff are not meeting residents nutritional needs. Staff are not meeting residents bathing needs. Staff are leaving residents soiled for an extended period of time.

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced complaint investigation visit. LPA met with Executive Director (ED) Alex Baiasu. LPA stated the purpose of the visit. On 8/14/2025 the Department conducted a complaint investigation visit. On 8/26/2025 the Department interviewed the Reporting Party (RP). RP states he/she observed a resident, referred to as R1, for approximately 4 hours on 8/10/2025 and R1 stated facility staff were not feeding him/her and not taking him/her to eat in the dining area. RP did not provide additional information. Page 1 of 4 Unsubstantiated On 8/14/2025 the Department conducted a complaint investigation visit and obtained documentation. On 9/18/2025, 4/6/2026 and 4/20/2026 the Department interviewed 4 Staff, (S1 to S4), 3 Residents (R2 to R4), and 1 Witness. 4 Out of 4 staff stated he/she is not aware of residents not receiving meals or not being taken to the dining hall for meals. S3 stated R1 had a personal preference to eat in his/her room. On 4/20/2026 the Department interviewed 3 Residents (R2 to R4). 3 Out of 3 residents stated he/she does not need assistant with receiving his/her meal and does not need to be taken to the dining hall. 3 Out of 3 residents state he/she has no issues or concerns with receiving his/her meals. On 4/9/2026, the Department interviewed 1 Witness (W1). W1 states he/she has no issues or concerns with the care that R1 is receiving at the facility. Review of R1’s physician’s report dated 3/21/2024, R1’s Capacity for Self-Care notes R1 can feed his/her own self. Review of R1’s care plan dated 8/19/2025, R1 “is on a regular diet and can determine his/her own food choices. Staff are not meeting residents bathing needs On 8/26/2025 the Department interviewed the Reporting Party (RP). RP states he/she observed a resident, referred to as R1, for approximately 4 hours on 8/10/2025 and R1 stated facility staff were not bathing him/her. On 9/18/2025, 4/6/2026 and 4/20/2026 the Department interviewed 4 Staff, (S1 to S4), 3 Residents (R2 to R4), and 1 Witness. 4 Out of 4 staff stated he/she assists residents with bathing/showering. S2 stated the facility has a shower schedule, and residents pick the days and times he/she prefers to bathe/shower. Page 2 of 4 S3 states there was one incident when R1 did not want to bathe. S3 did not remember the date or time of this incident. On 4/20/2026 the Department interviewed 3 Residents (R2 to R4). 3 Out of 3 residents state he/she does not require assistance with bathing/showering. 3 Out of 3 residents state he/she has no issues or concerns with the care he/she is receiving. On 4/9/2026, the Department interviewed 1 Witness (W1). W1 states he/she has no issues or concerns with the care that R1 is receiving at the facility. Review of the facility's Weekly Shower Schedule Brookdale Scotts Valley- Personalized Assisted Living, dated Thursday, August 14, 2025, R1 listed on schedule for Mondays at 3PM and Thursdays at 3PM. Review of R1's progress notes dated 6/13/2025 to 8/14/2025, there are no noted incidents of R1 not wanting to shower/bathe. Review of R1's Personal Service Plan for R1 dated 3/20/2025, R1 requires physical assistance with shampooing hair, washing upper and lower body. Staff are leaving residents soiled for an extended period of time. On 8/26/2025 the Department interviewed the Reporting Party (RP). RP states he/she observed a resident, referred to as R1, for approximately 4 hours on 8/10/2025 and alleges staff are leaving residents soiled for an extended period of time. On 9/18/2025, 4/6/2026 and 4/20/2026 the Department interviewed 4 Staff, (S1 to S4), 3 Residents (R2 to R4), and 1 Witness. 4 Out of 4 staff stated he/she is not aware of and has not observed a resident left soiled for an extended period of time. Page 3 of 4 On 4/20/2026 the Department interviewed 3 Residents (R2 to R4). 3 Out of 3 residents state he/she does not require assistance with toileting. 3 Out of 3 residents state he/she has no issues or concerns with the care he/she is receiving. On 4/9/2026, the Department interviewed 1 Witness (W1). W1 states he/she has no issues or concerns with the care that R1 is receiving at the facility. Review of R1’s physician’s report dated 3/21/2024, R1’s Capacity for Self-Care notes R1 can manage his/her own toileting needs, and R1 is not incontinent of bladder. Review of R1's Personal Service Plan for R1 dated 3/20/2025, R1 does not require toileting assistance. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with ED and a copy of this report was provided to S1. Page of 4 of 4 END OF REPORTthe state’s words, verbatim · CDSS document, Apr 20, 2026 · control 26-AS-20250813113122

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

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced Case Management to conduct a Quarterly Visit and met with Executive Director (ED) Alex Baiasu. The purpose of the visit is to ensure the facility is adhering to the Facility's Action Plan submitted to Community Care Licensing (CCL) after an Informal Conference meeting held on 8/13/2024. During visit, LPA reviewed staff training on personal rights and proper resident approach, as part of the facility's Action Plan submitted to the Department on 8/20/2024. LPA reviewed documentation of staff training conducted on 1/30/2026, 3/25/2026 which included but not limited to topics such as Resident Approach/Resident Rights, and Safe Resident Handling. ED stated staff are also checking on residents during the overnight shift as well. The facility is adhering to the facility's Action Plan for staff training. No deficiencies cited per California Code of Regulations, Title 22. This report was reviewed with Executive Director (ED) Alex Baiasu and a signed copy of this report was providedthe state’s words, verbatim · CDSS document, Mar 26, 2026

Allegation investigated: Facility does not have enough staff to meet residents needs. Resident sustained a pressure injury while in care.

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced visit to deliver complaint findings. LPA met with Executive Director (ED) Alex Baiasu. LPA stated the purpose of the visit. On 9/17/2025 the Department received a complaint with the above allegations. On 9/18/2025 the Department interviewed Reporting Party (RP). RP states when he/she visits a resident, referred to as R1, the facility “takes over 15 minutes” to respond to resident’s call button. RP states on 9/16/2025, R1 pressed his/her pendant and staff took over 30 minutes to respond. RP states staff came to R1’s room after 30 minutes. Page 1 of 3 Unsubstantiated On 9/18/2025 the Department conducted the initial complaint investigation visit. On 9/18/2025, 10/6/2025 the Department interviewed the Executive Director (ED), 2 Staff (S1 to S2) and 2 Witnesses (W1 and W2). ED states residents are checked on by staff according to each resident’s care plan. On 9/19/2025, 9/23/2025, 9/30/2025, the Department interviewed 2 Staff (S1 to S2). 1 Out of 2 Staff state the facility has enough staff to meet residents’ needs. S1 states the facility is short staffed, and residents don’t get his/her showers. S1 did not provide additional information regarding these incidents. S2 states the facility is not short staffed, and there has never been a time he/she did not respond to or assist residents with his her care needs. On 9/30/2025 and 10/6/2025 the Department interviewed 2 Witnesses (W1 and W2). W1 states ‘there is no routine to staff checking on residents.” W1 did not provide additional information. W2 did not provide additional information regarding staffing. Review of R1’s progress notes dated 9/17/2025 to 9/23/2025, R1 was observed by facility staff, and medications were administered per doctors’ orders. No noted incidents of staff not responding to residents call button. Resident sustained a pressure injury while in care. On 9/18/2025 the Department interviewed Reporting Party (RP). RP states a resident, referred to as R1, sustained a pressure injury on 9/18/2025. RP states he/she received a call from facility staff regarding a ‘wound’ observed on R1 on 9/18/2025. RP states R1’s care team was informed (physician and responsible party). On 10/6/2025 the Department interviewed the Executive Director (ED) ED states R1 is receiving home health care since August 2025. ED states if home health agency staff observe any wounds or pressure injuries, they are to inform the facility. ED states home health agency reported on 9/12/2025 and 9/16/2025 R1’s skin was ‘clear.’ ED states the facility became aware of R1 having a wound on 9/17/2025. ED states R1 care team and responsible party were notified of the wound on 9/17/2025. ED states on 9/19/2025 the facility spoke with home health care and was informed that home health care did not communicate the wound due to home health care calling the wrong number (facility). ED states this incident is documented on R1’s progress notes. Page 2 of 3 On 9/30/2025 and 10/6/2025, the Department interviewed 2 Witnesses (W1 and W2). W1 states he/she observed R1’s skin to be ‘clear’ on 9/12/2025. W1 states he/she became aware of R1’s wound on 9/17/2025 and R1’s doctor was informed. W1 did not state how he/she became aware of R1's wound. W1 states facility staff were informed on 9/17/2025 of R1’s wound. W2 states he/she did not observe a wound on R1. W2 states he/she was informed of the wound by RP on 9/19/2025. W2 did not provide additional information. LPA reviewed R1’s progress notes dated 9/17/2025 to 9/23/2025. On 9/17/2025 facility staff observed a wound on R1's skin, and R1’s care team was notified (physician and responsible party). On 9/19/2025 the facility followed up with R1’s responsible party, physician and home health agency regarding the care for R1's wound. Per progress note on 9/19/2025, “home health returned call, stated they communicated wound to PCP (physician) but not to care team. Per coordinator they were calling the wrong number.” Review of home health progress notes for R1 dated 8/28/2025 to 9/22/2025, notes on 9/12/2025 R1 skin's was observed as ‘intact.’ On 9/16/2025, R1’s skin was observed to have “no open areas or non-blanchable redness.” On 9/19/2025 home health documented a wound for R1, “R1’s wound had increased severely over the last 2 days.” Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were cited during today’s visit. An exit interview was conducted, and a copy of this report was provided. Page 3 of 3 END OF REPORT.the state’s words, verbatim · CDSS document, Feb 18, 2026 · control 26-AS-20250917153212

Allegation investigated: Staff did not provide proper transfer assistance to resident in care Staff did not attend to residents in care in a timely manner Staff did not ensure resident's room was clean and sanitary Staff are not following infection control protocol Staff engaged in verbal argument in front of resident

Licensing Program Analyst (LPA) Marcella Tarin conducted a complaint investigation to deliver the complaint findings for the above allegations. LPA met with Executive Director (ED). LPA stated the purpose of the visit. On 5/5/2025 the Department received a complaint with the above allegations. On 5/6/2025 the Department interviewed the Reporting Party (RP). RP states he/she observed facility staff transfer a resident, referred to as R1, by ‘bear-hugging’ the resident. RP did not provide additional information regarding this incident. Page 1 of 4 Unfounded On 5/6/2025 and 5/14/2025 the Department conducted complaint investigation visits and interviewed 6 Staff (S1 to S6) and 9 Residents (R1 to R9). 6 Out of 6 Staff stated he/she has had training on transferring residents. On 5/6/2025 and 5/14/2025 the Department interviewed 9 Residents. 7 Out of 9 Residents state he/she does not require transfer assistance from staff. R1 and R2 state staff help him/her with transfer assistance. R2 states one staff member doesn’t ‘do his/her job very well.’ R2 did not provide additional information regarding this incident. Review of staff training records from January 2025 to July 2025 to include but not limited to resident rights, resident communication, approach, handling and de-escalation. Staff did not attend to residents in care in a timely manner On 5/9/2025 and 5/14/2025 the Department interviewed 6 Staff (S1 to S6). 6 Out of 6 Staff stated he/she attends to residents in care in a timely manner. On 5/9/2025 and 5/14/2025 the Department interviewed 9 Residents (R1 to R9). 4 Out of 9 Residents state staff attend to him/her in a timely manner. 5 Out of 9 Residents states he/she does not use pendants. On 5/9/2025 the Department tested R2’s pendant and staff responded in under 5 minutes. On 5/14/2025 the Department conducted an additional test of pendant response times. R9’s pendant was tested, and staff responded in 3 minutes. Staff did not ensure resident's room was clean and sanitary On 5/6/2025 the Department interviewed the Reporting Party (RP). RP states he/she observed R1’s toilet to need a cleaning, and R1's room had an odor. Page 2 of 4 On 5/9/2025 and 5/14/2025 the Department interviewed 6 Staff (S1 to S6). 6 Out of 6 Staff states resident rooms are cleaned at least once a week by housekeeping. S1 states if he/she observes a resident’s room to have trash on the floor, he/she will pick up the trash. S1 states if he/she observed a toilet in need of cleaning, he/she will inform housekeeping. On 5/9/2025 and 5/14/2025 the Department interviewed 9 Residents (R1 to R9). 9 Out of 9 residents state staff clean his/her room. On 5/14/2025, LPA Monter observed 4 random resident rooms as clean, sanitary, odor free, and in good repair. Staff are not following infection control protocol On 5/6/2025 the Department interviewed the Reporting Party (RP). RP states he/she observed a staff member change a resident without using gloves and the staff did not wash his/her hands. On 5/9/2025 and 5/14/2025 the Department interviewed ED. ED states all staff have infection control protocol and wear gloves when caring for residents. ED states he provides this training directly to staff, and ensures staff follow protocol by conducting random checks on staff to ensure staff are wearing gloves and washing hands after caring for a resident. On 5/9/2025 and 5/14/2025 the Department interviewed 5 Staff (S1 to S5). 5 out of 5 staff state he/she has had infection control protocol training and wear gloves and wash his/her hands before and after caring for residents. S1 states he/she always carries gloves in his/her apron and pulled out gloves to show LPAs during the interview. On 5/9/2025 and 5/14/2025 the Department interviewed 9 Residents (R1 to R9). 4 Out of 9 Residents states staff wear gloves and staff wash hands when providing care to him/her. 5 Out of 9 staff state he/she does not know if staff wear gloves or wash hands. R3, R4, R5, R6, R7, and R8 state he/she doesn’t pay attention to whether staff are wearing gloves or washing hands. Page 3 of 4 Staff engaged in verbal argument in front of resident On 5/6/2025 the Department interviewed the Reporting Party (RP). RP states on 4/29/2025 he/she engaged in an argument with staff in front of R1. On 2/6/2026, the Department interviewed ED. ED states he is not aware of any staff arguing in front of residents at any time. On 5/9/2025 and 5/14/2025 the Department interviewed 5 Staff (S1 to S5). 5 out of 5 staff state he/she is not aware of any staff arguing in front of residents. On 5/9/2025 and 5/14/2025 the Department interviewed 9 Residents (R1 to R9). 9 Out of 9 residents state he/she is not aware of any staff arguing in front of residents. Review of staff training records from January 2025 to July 2025 to include but not limited to topics such as resident rights, resident communication, approach, handling and de-escalation. This agency has investigated the complaint alleging staff did not provide proper transfer assistance to resident in care, staff did not attend to residents in care in a timely manner, staff did not ensure resident's room was clean and sanitary, staff engaged verbal argument in front of resident. We have found that the complaint was UNFOUNDED meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with Executive Director (ED) Alex Baiasu and a copy of this report was provided. Page 4 of 4 END OF REPORTthe state’s words, verbatim · CDSS document, Feb 6, 2026 · control 26-AS-20250502135854

Allegation investigated: Facility is charging resident for services not rendered.

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced complaint investigation visit to deliver the finding on the above allegation. LPA met with Executive Director (ED) Alex Baisu. On 6/2/2025 the Department received a complaint with the above allegation. On 6/4/2025 the Department conducted a complaint investigation visit and interviewed 1 Staff and 3 Residents. Staff S1 states residents. On 6/3/2025 and 2/5/2026 the Department requested information from the Reporting Party (RP). On 2/6/2026 the Department interviewed RP. RP states the issue has been resolved and the charges were not related to services at the facility. Page 1 of 2 Unfounded RP states R1 was not evicted from the facility in March 2025. RP states R1 owed fees to the facility in March 2025. Review of R1’s invoice dated 3/12/2025 notes invoices from 5/2024 to 10/16/2024 for ‘Monthly Invoices’ for $403. Review of R1’s Account History Report from 1/14/2022 to 5/30/2025 does not note R1 "Monthly invoices" in the amount of $403. Review of R1’s Account History Report from 1/14/2022 to 5/30/2025 does not show any charges for oxygen concentrators or transportation services. R1’s Account History Report notes R1 owes facility fees related to late payments and not paying his/her balance in full as of 5/30/2025. On 2/6/2026 the Department interviewed S1. S1 states R1 was not evicted in March 2025 and R1 currently resides at the facility. S1 states the facility continues to work with R1 in getting him/her to paying his/her balance. Review of R1’s Admission Agreement notes R1 moved into the facility on 12/31/2021. This agency has investigated the complaint alleging Facility is charging residents for services not rendered. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with Executive Director (ED) Alex Baiasu and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 6, 2026 · control 26-AS-20250602141402

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

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced Case Management to conduct a Quarterly Visit and met with Executive Director (ED) Alex Baiasu. The purpose of the visit is to ensure the facility is adhering to the Facility's Action Plan submitted to Community Care Licensing (CCL) after an Informal Conference meeting held on 8/13/2024. During visit, LPA reviewed staff training on personal rights and proper resident approach, as part of the facility's Action Plan submitted to the Department on 8/20/2024. LPA reviewed documentation of staff training conducted on 2/28/2025, which included but not limited to topics such as Resident Approach/Resident Rights, and Safe Resident Handling. ED stated the facility has promoted and trained 3 additional staff to supervisory positions to ensure staff are adhering to Title 22 policies. LPA observed the Training Attendance Form was signed by facility care staff. ED states random check-ins are conducted daily with staff to ensure adherence to resident's personal rights and proper approach protocols. ED states there are also random checks on residents during the overnight shift as well. ED states an additional training was provided by Adult Protective Services (APS) during a facility Townhall meeting in August 2025. The facility is adhering to the facility's Action Plan for staff training. No deficiencies cited per California Code of Regulations, Title 22. This report was reviewed with Executive Director (ED) Alex Baiasu and a signed copy of this report was providedthe state’s words, verbatim · CDSS document, Dec 29, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to conduct a Case Management-Other visit to amend the findings of Complaint 26-AS-20250724093244. LPA met with Executive Director (ED) Alex Baiasu. LPA stated the purpose of the visit. During the visit, LPA amended Complaint 26-AS-20250724093244 findings from unsubstantiated to unfounded. LPA inadvertently did not update the amended report to reflect the date 10/23/2025 and time of visit from 9:45 AM to 10:35 AM. The amended report incorrectly lists the date as 08/01/2025 and time of visit from 9:45 AM to 11:30 AM. No deficiencies were cited during today's visit. An exit interview was conducted with ED, and a signed copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 23, 2025

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Marcella Tarin and Marcela Yanez conducted an unannounced annual inspection and met with Executive Director (ED) Alex Baiasu. LPAs stated the purpose of the visit. LPAs toured the interior and exterior of the facility with ED to include the kitchen, resident rooms, dining room, bathrooms, activity room,pool/billiards area, hair salon, movie theater, gift shop, and resident gym. LPAs observed 20 residents during morning activity exercises (B-Fit Class), and a barbecue area in the back of the facility. All exit and passageways were free and clear of obstruction. LPAs toured the kitchen area and observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPAs observed refrigerator thermostat temperature at 40F and Freezer at -2F. LPAs observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to clients in care. The facility was equipped with smoke and carbon monoxide detectors. Facility smoke detectors and carbon monoxide detectors and sprinklers were inspected by a third party vendor on 5/15/2025 and passed inspection. The last disaster drill was conducted in July 2025. LPAs reviewed the emergency disaster log and drills were conducted in May, June and July of 2025. Page 1 of 2 LPAs toured 10 resident bathrooms. 8 out of 10 bathrooms had hand soap, paper towels, functioning lights, and covered trash bins. 2 resident bathrooms were in use during time of inspection. LPAs measured water temperature with a range of 105.2 F to 116.2 F. LPAs reviewed 10 resident records. Resident records included emergency contact information, physician’s report, needs and service plans, and personal rights. At 1:30PM LPAs reviewed 5 resident’s Centrally Stored Medication and Destruction Records (CSMDRs). A Technical Violation is being issued see LIC 9102 for more information. LPAs reviewed 10 staff records. Staff records included fingerprint background clearance, medical assessment with TB result, personnel record, and staff training. No deficiencies were cited during today's visit per California Code of Regulations Title 22. A Technical Violation was issued, see LIC9102. An exit interview was conducted with Executive Director (ED) Alex Baiasu and a signed copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 11, 2025

Allegation investigated: Staff do not permit residents' to choose their pharmacy Staff did not notify resident's responsible party of fee increase

This is an amended report 10/23/2025 to change the findings from unsubstantiated to unfounded. Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to conduct the initial complaint investigation visit. LPA met with Executive Director (ED) Alex Baiasu. LPA stated the purpose of the visit. On 7/24/2025 the Department received a complaint with the above allegations. During the visit, LPA interviewed 1 Staff and ED. On 7/30/2025 LPA interviewed Witness 1 (W1). W1 stated the facility did not allow R1 to choose his/her own pharmacy, and was not notified of the fee increases for the pharmacy. Page 1 of 2 Unfounded This is an amended report 10/23/2025 to change the findings from unsubstantiated to unfounded. W1 stated he/she had a meeting on 7/28/2025 and came to a 'mutual agreement' regarding the choice of pharmacy and fees for Resident R1. W1 stated the facility refunded the pharmacy fees charged to R1. W1 stated he/she agreed with the terms of pharmacy and was 'satisfied.' W1 stated R1 received the letter regarding the pharmacy but did not understand the pharmacy change. LPA interviewed ED. ED states all residents were informed of the preferred pharmacy and fees by letter on 5/27/2025. ED states residents still have the option to choose their own pharmacy. ED stated the facility had a meeting with W1 on 7/28/2025 regarding the choice of pharmacy and fees for R1. ED stated the facility explained to W1 the terms of the preferred pharmacy for R1. ED stated W1 agreed with the terms for the preferred pharmacy for R1. LPA interviewed Staff S1. S1 states he/she was part of the meeting with W1 and ED on 7/28/2025. S1 stated he/she explained how the preferred pharmacy would work for R1. S1 stated W1 agreed to the terms of the preferred pharmacy. LPA reviewed R1's Resident Pharmacy Enrollment Form dated and signed by W1 on 7/28/2025. LPA reviewed a letter from the facility dated 5/27/2025, informing residents about the facility preferred pharmacy and fees. The letter states " For residents who do not choose to utilize the preferred pharmacy, charges will begin on...July 2025. Please note that residents were notified of this charge either upon moving in or their annual rate adjustment letters sent earlier this year." This agency has investigated the complaint alleging staff do not permit residents' to choose their pharmacy, and staff did not notify resident's responsible party of fee increase. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was provided. No deficiencies were cited during today’s visit based on California Code of Regulations (CCR) Title 22. An exit interview was conducted with Executive Director (ED) Alex Baiasu. A signed copy of this report was provided. Page 2 of 2 End of Report.the state’s words, verbatim · CDSS document, Aug 1, 2025 · control 26-AS-20250724093244

Allegation investigated: Staff did not ensure feeding assistance was provided to resident in care Staff allowed resident to be left in soiled clothing for extended periods of time Staff did not reposition resident

On 1/24/2025 the Department received a complaint alleging the above allegations. On 1/31/2025 the Department conducted an unannounced initial investigation, interviewed staff and requested copies of resident’s records to be sent to CCLD by 2/03/2025. On 1/31/2025 - LPA Marrufo interviewed staff (S1 to S4) 4 Out of 4 staff stated residents in palliative care are checked, repositioned and changed every two hours. 4 Out of 4 staff stated that residents in palliative care are assisted with feeding when resident requests for assistance. On 2/3/2025 - LPA Marrufo interviewed 2 witnesses and attempted to interview 1 (W1, W2, W3). W1 stated he/she did not have information about a staff member regarding feeding assistance to a resident. W1 stated they have no safety issue report or concern with R1s care. Page 1 of 3 Unsubstantiated W1 stated that W3 is not part of a care team and screamed at the staff who just checked on R1. W1 stated that W3 was angrily screaming at staff who just cared for R1 and stated that R1 was not being cared for properly. W2 cannot be contacted. W3 stated that he/she did not see the compromised skin of R1 and does not know R1s care plan. W3 stated that he/she had a feeling that nothing was done, no photos were taken. W3 stated that a Home Health Care comes to the facility to care for R1 three times a week. W3 stated family and himself/herself visited R1 and stated R1s hair was washed and bed was ‘spic and span’. On 5/23/2025 LPA Tarin interviewed W4. W4 stated he/she provided care for R1, assisted with feeding when R1 requests for assistance. On 4/4/2025, 4/24/2025 and 5/14/2025, LPAs interviewed 11 staff (S1-S11) and 10 residents (R1-R10). Based on interviews, 7 out of 11 staff (S1-S11) stated staff provides feeding assistance to residents. 4 out of 11 staff stated they work the nocturnal shift, and meals are not provided during this time. Based on interviews 10 out of 10 (R1-R10) residents stated they do not need assistance from staff with feeding. Staff allowed resident to be left in soiled clothing for extended periods of time Based on interviews, 7 out of 11 staff (S1-S11) stated they did not observe a resident left in soiled clothing for extended periods of times. 3 out of 11 staff stated they observed a resident left in soiled clothing. 1 out of 11 staff did not provide any information. Based on interviews, 10 out of 10 residents (R1-R10) stated they have not observed a resident left in soiled clothing for extended period of time. On 5/23/2025 LPA Tarin interviewed W4. W4 stated he/she did not observe R1 in soiled clothing for extended period of time. Staff did not reposition resident Page 2 of 3 Based on interviews, 10 out of 11 staff (S1-S11) stated they reposition residents based on their care plan. 1 Out of 11 staff did not provide any information. Based on interviews, 10 out of 10 residents (R1-R10) stated he/she does not need repositioning. On 5/23/2025, LPA Tarin interviewed W4. W4 stated he/she repositioned R1. W4 stated there were occasions when R1 did not allow him/her to be repositioned. W4 could not provide exact dates when R1 refused to be repositioned. Based on document review of resident care plans, 1 out of 4 residents were under hospice care. 1 out of 4 residents were diagnosed with a terminal illness and major neurocognitive disorder. 3 out of 4 residents do not require feeding assistance based on the care plan. 1 out of 3 residents care plan stated that residents in hospice care are repositioned, checked and cleaned every 2 hours. Based on interviews, document reviews and observations, although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the above allegations are unsubstantiated. No deficiencies were cited during today’s visit based on California Code of Regulations (CCR) Title 22. An exit interview was conducted with Executive Director (ED) Alex Baiasu via phone and authorized S1 to sign on his behalf. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jun 4, 2025 · control 26-AS-20250124092401

Allegation investigated: Staff are not answering residents' call button in a timely manner Staff yelled at resident Resident is not being accorded dignity in personal relationship with staff at facility Staff are not following doctor's orders for prescription medication Facility is not following admission agreement to deliver food to resident

On 12/5/2024 the Department received a complaint alleging that facility staff are not answering resident’s call button in a timely manner. It has been alleged facility staff took 35 minutes to respond to a call in July 2024. On 12/11/2024 the Department conducted an unannounced initial investigation. On 12/11/2024, 4/4/2025, 4/24/2025 and 5/14/2025, LPAs interviewed 7 staff (S1-S7) and 11 residents (R1-R11). LPAs tested random call buttons at the facility on the following dates 4/4/2025, 4/24/2025 and 5/14/2025. LPAs tested 5 resident call buttons. Page 1 of 2. Unsubstantiated Based on random testing, 4 out of 5 residents call buttons were responded by staff in under 15 minutes. 1 out of 5 residents call buttons were responded by staff in 41 minutes. Staff yelled at resident Based on interviews, 5 out of 7 (S1-S7) staff stated staff did not yell at residents. 2 out of 7 staff stated he/she observed a staff yell at a resident. However, S3 and S5 staff did not provide information as to when the incident happened. Based on interviews, 10 out of 11 residents (R1-R11) stated that staff does not yell at residents. 1 out of 11 residents stated staff yelled at him/her. Resident is not being accorded dignity in personal relationships with staff at facility. Based on interviews, 5 out of 7 (S1-S7) staff stated staff did not yell at residents. 2 out of 7 staff stated he/she observed a staff yell at a resident. However, S3 and S5 staff did not provide information as to when the incident occurred. Based on interviews, 10 out of 11 residents (R1-R11) stated that staff does not yell at residents. 1 out of 11 residents stated staff yelled at him/her. Staff are not following doctor’s orders for prescription medication Based on interviews, 6 out 7 (S1-S7) staff stated staff are following doctor's orders for prescription medication. 1 out of 7 staff stated staff are not following doctor's orders for prescription medication. However, S3 did not provide information as to when the incident occurred. Based on interviews, 11 out of 11 (R1-R11) residents stated staff are following doctor’s orders for prescription medication, Page 2 of 3 LPA reviewed the facility Medication Administration Record (MAR) for 5 residents. LPA observed medications are being administered per doctor’s orders for all 5 residents. Facility is not following admission agreement to deliver food to resident Based on interviews, 5 out of 7 staff (S1-S7) stated meals are being delivered to residents. 1 out of 7 staff stated he/she works the overnight shift, and meals are not served during this time. 1 out of 7 state stated meals are not being delivered to residents but did not provide information as to when the incident occurred. Based on interviews, 5 out of 11 (R1-R11)residents stated he/she does not pay for meal delivery service. 5 out of 11 residents stated he/she pays for meal delivery services and receives his/her meals. 1 out of 11 residents stated he/she pays for meal delivery services and does not receive his/her meals. R1 stated that a day in December of 2024, his/her meal was not delivered. R1 did not provide additional information for other days meals were not delivered. Based on interviews, document reviews and observations, although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the above allegations are unsubstantiated. No deficiencies were cited during today’s visit based on California Code of Regulations (CCR) Title 22. An exit interview was conducted with Executive Director (ED) Alex Baiasu and a copy of the report was provided.the state’s words, verbatim · CDSS document, May 23, 2025 · control 26-AS-20241205143226

Allegation investigated: Staff are not allowing resident to have visitors Staff are inappropriately isolating resident Staff are inappropriately punishing resident Staff are mismanaging residents medication Unqualified staff is administering medication to residents

Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegations. LPA met with Executive Director Alex Baiasu. On September 19, 2024, the Department received a complaint alleging Staff are not allowing resident to have visitors. It has been R1’s family member cannot visit R1. On September 27, 2024, LPA Steve Chang and Marcella Tarin conducted an unannounced initial investigation visit. On September 27, 2024, LPA Steve Chang and Marcella Tarin interviewed resident R1. R1 stated his/her wife/husband can come at any time. Page 1 Out of 5. Unfounded LPA Chang and Tarin interviewed Executive Director (ED). ED stated visitors can visit anytime, 24 hours a day. ED stated the only time a visitor is refused is when the resident refuses a visitor. On April 4, 2024, LPA Monter and Tarin interviewed residents R2-R5. All residents interviewed stated; the facility allows residents to have visitors. All residents interviewed stated the facility does not ban or block visitors from visiting their family members. On April 4-21, 2025, LPA Monter interviewed staff S4-S8. All staff interviewed stated the facility allows residents to have visitors. All staff interviewed stated the facility does not ban or block visitors from visiting their family members. On April 24, 2025, LPA Monter interviewed residents R6-R13. All residents interviewed stated; the facility allows residents to have visitors. All residents interviewed stated the facility does not ban or block visitors from visiting their family members. The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. Staff are inappropriately isolating resident/Staff are inappropriately punishing resident On September 19, 2024, the Department received a complaint alleging Staff are inappropriately isolating resident / Staff are inappropriately punishing resident. It has been alleged that facility staff are punishing resident R1 by isolating him/her. On September 27, 2024, LPA Steve Chang and Marcella Tarin conducted an unannounced initial investigation visit. On April 4, 2024, LPA Monter and Tarin interviewed residents R5-R8. All residents interviewed stated; they have not seen residents being punished or residents isolated by staff. Page 2 Out of 5 On April 4-21, 2025, LPA Monter interviewed staff S4-S8. All staff interviewed stated they haven’t seen residents being punished or residents isolated by staff. On April 24, 2025, LPA Monter interviewed residents R9-R13. All residents interviewed stated; they have not seen residents being punished or residents isolated by staff. On May 14, 2025, LPA Monter interviewed R1. Resident R1 stated he/she was not being isolated or punished. The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. Staff are mismanaging residents medication On September 19, 2024, the Department received a complaint alleging Staff are mismanaging residents medication. It has been alleged that staff are not administering residents insulin shots. On September 27, 2024, LPA Steve Chang and Marcella Tarin conducted an unannounced initial investigation visit. On April 4, 2024, LPA Monter and Tarin interviewed residents R5-R8. Residents R2, R3, R5 stated they have been getting their medications everyday and have not had a missed medication. Resident R4 stated he/she handles his/her own medication and doesn’t need staff assistance. On April 4-21, 2025, LPA Monter interviewed staff S4-S8. S4 stated Staff S1 wasn’t administering medication to residents. S4 stated staff S1 is marking on the computer that he/she administered medication, but he/she is lying on the form. S5 - S8 stated residents are getting their medications and there hasn’t been a day when medication was missed. Staff S5-S8 stated they have not observed staff making up dosages on residents medications. Page 3 Out of 5 On April 4-21, 2025, LPA Monter interviewed staff S4-S8. S4 stated Residents are not being showered because of being short of staff. S4 stated resident R1 isn’t receiving a shower. S4 stated R1 is being showered every 2 weeks. S5 stated There are times when staff are short staff. S5 Stated when staff are busy, they can’t meet shower schedule and need to move time of shower, but the resident is showered the same day. S5 stated he/she has not seen residents who appeared unshowered or neglected in terms of their hygiene. S6 stated he/she will sometimes find residents unshowered at the start of his/her shift, but he/she will shower the residents. Staff S7 stated the residents are being showered. S7 stated residents have 2 shower days a week minimum. S8 stated he/she has found residents not showered. S8 stated the residents are eventually showered, but the short staffing makes delays. On April 24, 2025, LPA Monter interviewed residents R6-R10. Resident R6 stated he/she gets assistance with showers and has no complaints. R7 and R9 stated they get showered from his/her family member and does not need assistance from the facility staff. R8 stated because the facility is short staffed, the shower schedule has been inconsistent. R8 stated he/she would get his/her shower every 2 weeks. R10 stated he/she does not need assistance from facility staff to take a shower. All residents interviewed stated they have not seen any residents who appeared unshowered or neglected in terms of their hygiene. On May 14, 2025, LPA Monter interviewed resident R1. Resident R1 stated he/she is getting his showers weekly. R1 stated he/she does refuse showers sometimes because he/she doesn't like to deal with the hassle of showering. Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. On April 24, 2025, LPA Monter interviewed residents R9-R13. Resident R6 & R8 stated they have been getting their medications everyday and have not had a missed medication. R10, R12 & R13 stated he/she handles his/her own medication and doesn’t need staff assistance. On May 14, 2025, LPA Monter interviewed residents R1, R2, R4 & R14. All residents interviewed stated they have been getting their medications everyday. All residents interviewed stated there hasn't been a day when medication has been missed. The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. Unqualified staff is administering medication to residents On September 19, 2024, the Department received a complaint alleging Unqualified staff is administering medication to residents. It has been alleged that a staff member who is unqualified to administer shots, S1, has been administering shots. On September 27, 2024, LPA Steve Chang and Marcella Tarin conducted an unannounced initial investigation visit. On September 27, 2024, LPA Chang and Tarin interviewed staff S1. S1 stated he/she does not have his/her license yet, but I have nclex (State board licensing) next month to obtain license for LVN. S1 stated he/she has a permit, but it expired. S1 stated the permit means you can only practice with another nurse. S1 stated he/she cannot practice independently. S1 stated he/she was able to administer and inject insulin before his/her permit expired. Based on a review of S1’s staff file, S1’s interim permit from the board of vocational nursing was issued on November 6, 2023 and valid until August 6, 2024. S1’s Vocational Nurse license was issued on October 22, 2024, with an expiration date of August 31, 2026. Page 4 Out of 5. On May 14, 2025, LPA Monter interviewed residents R2, R4 & R14. All residents interviewed stated they have been getting their medications everyday. All residents interviewed stated there hasn't been a day when medication has been missed. All residents interviewed stated they do not remember who administered their medication from August 7- October 21, 2024. LPA Manuel Monter reviewed resident insulin administration log for the months of August and October 2024. LPA reviewed 3 resident insulin, E-Mar. Based on a review, Staff S1 didn't administer insulin medications based on what is stated on the E-mar, from the dates, August 7- October 21, 2024. The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. Page 5 Out of 5. END OF REPORT.the state’s words, verbatim · CDSS document, May 14, 2025 · control 26-AS-20240919113044

Allegation investigated: Staff did not notify authorized represenative that the resident went to the hospital Resident was left on floor for an extended period of time

Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegations. LPA met with Administrator Alex Baiasu. On October 25, 2023, the Department received a complaint alleging Staff did not notify authorized representative that the resident went to the hospital. It has been alleged that On August 18, 2023, R1 suffered a medical emergency and was sent the hospital. It has been alleged the facility did not notify the family of the 911 call. On March 28, 2025, LPA Monter interviewed R1’s family member (FM). FM stated he/she doesn’t know if the facility contacted him/her the same day or within 24 hours. FM stated he/she doesn’t know if R1’s power of attorney was contacted on August 18, 2023. Page 1 Out of 4. Unsubstantiated On April 4, 2024, LPA Monter interviewed R1’s Power of Attorney. (POA). POA stated he/she thinks he/she was not contacted but cannot say for sure. POA stated it was a long time ago. On April 4, 2024, LPA Monter interviewed staff S1. Staff S1 stated he/she did recall the incident regarding R1, and he/she having to move bedrooms due to the mice issue. Staff S1 stated he/she did call the POA and informed him/her that R1 was going to the hospital on August 18, 2023. S1 stated the POA was contacted almost immediately. Based on a review of Resident R1’s progress notes, dated August 18, 2023, R1 was transferred to a different room because his/her room had mouse issues. R1 was sitting in his/her wheelchair while maintenance was fixing his/her bed. R1 was unresponsive and started to throw up. R1 was sent out to the hospital. R1’s responsible party was notified by staff S1. Based on a review of the facility program, "whenever a resident needs medical attention, an immediate, on the spot assessment must be made of the resident's condition...if the resident is comatose or incoherent...call the relative or person listed on the card...if the resident is conscious and has requested assistance...contact the relative or person listed on their card..." The Department was unable to interview Resident R1, who no longer lives at the facility. Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. Resident was left on floor for an extended period of time On October 25, 2023, the Department received a complaint alleging resident was left on floor for an extended period of time. It has been alleged that in July 2023, resident R1 had fallen out of bed and was out of bed for over 2 hours before assistance arrived. Page 2 Out of 4. On March 28 2025, LPA Monter interviewed R1’s family member (FM). FM stated he/she doesn’t know how long R1 was laying on the floor when he/she fell on July 1, 2023. FM stated he/she only knows what R1 told him/ her. On April 4, 2025, LPA Monter and Tarin interviewed residents R2-R5. All residents interviewed stated they have not seen residents who were left on the ground unattended for an extend period of time. Residents R2 and R3 stated the facility staff respond to pendants in a timely manner. Resident R4 stated he/she has never used the pendant or call bell system. Resident R5 stated he/she has used his/her pendant/ call bell system. R5 stated the staff does not respond timely. R5 stated especially at night, staff will respond in 45 minutes. On April 4, 2025, LPA Monter tested the pendant pull cord system in resident bedroom 247. The facility staff responded to the activated pendant/cord system and arrive to the residents bedroom in 10 minutes and 30 seconds. LPA Monter also tested the cord system in bedroom 414. Facility staff were able to respond and arrive to the residents bedroom, in four minutes. On April 4 2025, LPA Monter interviewed R1’s power of attorney (POA). POA stated he/she doesn’t know how long R1 was laying on the floor when he/she fell on July 1, 2023. FM stated he/she only knows what R1 told him/her. On April 2025, LPA Monter interviewed staff S2-S5. S2 stated he/she was not working when R1 got stuck in the bed rails. S3 stated he/she does remember resident R1 but doesn’t remember when R1 got stuck. S3 stated it was a long time ago, and has a rough glimpse of that day, but doesn’t recall. Staff S4 stated he/she remembers the fall that R1 had on July 1, 2023. S4 stated R1 had his/her hand stuck. S4 stated it was one of the night shift care givers responded that night, immediately. S4 stated she doesn’t remember who it was but stated it might be either S3 or S2. Page 3 Out of 4. Based on a review of R1’s Progress notes, dated July 1, 2023, at around 3:10 in the morning, resident called thru his/her pendant. When staff arrived, R1 was on the floor, with his/her right-hand suck on the bed side rail. Staff helped R1, and 911 was contacted for more assessment. R1’s responsible party was contacted. The Department was unable to interview Resident R1, who no longer lives at the facility. Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. No deficiencies cited, an exit interview conducted with Administrator, Alex Baiasu and a copy of the report was provided. Page 4 Out of 4. END OF REPORT.the state’s words, verbatim · CDSS document, Apr 24, 2025 · control 26-AS-20231025155125

Allegation investigated: Staff are not meeting resident's laundry needs Staff did not ensure laundry machines were not in disrepair

On 1/17/2025 the Department received a complaint alleging that staff are not meeting resident’s laundry needs and staff did not ensure laundry machines were not in disrepair. On 1/25/2025 LPAs interviewed Witness 1 (referred to as W1). W1 stated he/she can’t say for sure if the facility failed to do the laundry twice a week. W1 stated he/she was doing laundry and went upstairs, and one of the laundry machine/dryers was not turning on, but eventually turned on. W1 stated he/she may not have known how to operate the laundry machine/dryer and is unsure if the laundry machine/dryer was in disrepair. On 1/23/2025, LPAs Marcella Tarin and David Maruffo conducted the initial complaint investigation. LPAs interviewed 6 staff (referred to as S1-S6), and residents (referred to as R1-R5) regarding the above allegations. Page 1 of 2 Unsubstantiated 4 Out of 6 staff (S1-S3, S6) state the laundry machines were not in disrepair. 2 out of 6 staff (S4 & S5) state that yes, the laundry machines have been in disrepair (broken/not working) and were replaced on the same day by the facility. LPA interviewed 5 residents. 5 Out of 5 residents state the laundry machines were not in disrepair. 3 Out of 5 residents state staff are meeting his/her laundry needs. 2 Out of 5 residents state staff are not meeting his/her laundry needs. R1 and R2 state there has been instances when his/her laundry was not returned the same day during his/her scheduled laundry day. LPAs interviewed the Administrator regarding the allegations. ADM states laundry service once a week is part of the facility’s basic service plan for all residents. ADM states that laundry machines (Washers/dryers) have broken down (not working) but that maintenance will repair or replace the laundry machines. During visit LPAs observed 15 washers and 15 dryers in 9 laundry rooms throughout the facility. All 15 washers and 15 dryers functioned properly when tested by staff. On 4/4/2025, LPAs interviewed 4 residents (R6-R9). All residents interviewed stated he/she has no issue with laundry service. All residents interviewed states he/she is not aware of laundry machines being in disrepair. Based on record review, the facility's resident admission agreement state that laundry service once a week is part of the facility’s basic plan for all residents. LPAs also reviewed the Weekly Laundry Schedule and R1-R9 are listed on the schedule for weekly laundry service. Page 2 of 3 Based on information from interviews conducted with staff, records reviewed and observation, although the allegations listed above 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. No Deficiencies were cited under California Code of Regulations Title 22. This report was reviewed with Executive Director Alex Baiasu and a copy of this report was provided. Page 3 of 3the state’s words, verbatim · CDSS document, Apr 4, 2025 · control 26-AS-20250117115850

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced Case Management to conduct a Quarterly Visit and met with Executive Director (ED) Alex Baiasu. The purpose of this visit is to ensure that the facility is adhering to the facility's Action Plan submitted to Community Care Licensing (CCL) after an informal meeting held on 8/13/2024. During visit, LPA reviewed staff training on personal rights and proper resident approach, as part of the facility's Action Plan submitted to the Department on 8/20/2024. LPA reviewed documentation of staff training conducted on 9/6/2024 which included topics such as Resident Approach/Resident Rights, and Safe Resident Handling. LPA observed the Training Attendance Form which was signed by facility care staff on 9/6/2024. ED states random check-ins are being conducted daily with staff to ensure adherence to residents personal rights and proper approach protocols. The facility is adhering to the facility's Action Plan for staff training. At 1:45PM LPA observed an all staff meeting being conducted by Management. No deficiencies cited as per California Code of Regulations, Title 22. This report was reviewed with Executive Director (ED) Alex Baiasu and a signed copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 15, 2025

Allegation investigated: Staff are not keeping accurate resident records.

According to a report from a Reporting Party (RP), the RP alleged that facility staff are inputting inaccurate information on resident's records. Based on records review of two resident files, LPA found errors for Resident 4 (R4) and Resident 5 (R5); however, the errors do not indicate staff purposely entered the error. The RP reported that a management staff that was employed in 2023 directed staff to do such in order to cover themselves. According to an interview with the current ED, that person is no longer an employee of Brookdale Scotts Valley. R4's Medication Administration Record (MAR) dated July of 2023 was reviewed. The MAR indicated that R4 did not receive a medication order for insulin prior to dinner on 07/03/23. According to the MAR, if a resident is given a medication, there would be a check mark along with a code number and staff initials. Continues on LIC 9099 - C... Substantiated Continues from LIC 9099 The staff code indicates which nurse administered the medication and the reason for entry. For 07/03/23, there was an X along with the code 09. According to the MAR legend, code 09 means "other/see nurse notes". LPA Valerio reviewed five out of five pages of nurse notes for July of 2023. LPA observed a note missing for 07/03/23 at 16:00, which does not show the reason for the missing entry. Due to this error, a person cannot determine if the resident did or did not receive the medication. R5's MAR dated July of 2023 was reviewed. Per R5's admission agreement, R5 moved into the facility on 06/30/2023. LPA Valerio observed all regularly scheduled medications to be missing a signature indicating medications were provided to the resident. The MAR showed the resident started receiving medications on 07/04/23. According to an interview with ED Alex, R5 moved in on 06/30/2023 and had a paper MAR until medications were interfaced by the pharmacist. If R5 moved into the facility on 06/30/23, R5 should have been given medications. According to ED Alex, R5 was not in the community from 06/30/2023 until 07/04/2023. Based on records review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC-9099D. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. An exit interview was conducted, and a copy of the report was left at the facility Continued from LIC 9099 - A Resident (R3) was said to have wounds on their legs. LPA Valerio reviewed facility records for 2023. LPA reviewed a skin assessment conducted on 04/23/23. The skin assessment showed no open wounds. The facility did not have any documentation showing R3 to have wounds in 2023. R4 was said to have wounds on their skin and R4's skin was rotten. LPA Valerio reviewed facility records for R4. The facility had all records for R4, except the resident's LIC 602 (medical assessment) for 2023. Medication Administrator Records (MAR) show the resident was prescribed multiple medications used to address skin related concerns. According to an interview conducted with R4 in 2024, R4 stated they did not have any complaints against the facility. Staff are not meeting residents’ diabetic care needs / Staff do not ensure residents take medications as prescribed. According to the RP, residents were neglected to have their blood sugar checked by facility staff on 07/03/2023 and 07/04/2023. LPA Valerio requested facility documentation for two (2) residents present in 2023 that needed to have their blood sugar checked prior to meal. According to MAR for R4, there was a physician order to have R4's blood sugar checked twice a day at 0800 and 2000 hours. Based on records review, the resident had their blood sugar checked at each time during both dates. LPA Valerio reviewed facility records for Resident 5 (R5). According to MAR for R5, R5 did not have an order to have blood sugar checks until 07/06/2023. Staff did not respond to resident’s calls for help. According to the RP. Resident 6 (R6) experienced a fall, pressed their call light, and staff did not respond all night. Based on records review, the R6 had a documented fall on 07/04/2023 and did not suffer a fall on any other date. LPA Valerio requested a copy of the unusual incident report submit for R6 along with a copy of R6's personal residential care plan. The facility was unable to produce these documents; therefore, no additional information could be obtained. According to Executive Director Alex Baiasu, the resident had one fall with no injuries and the no unusual incident report was required to send unless it involved hospital transfers. Continues on LIC 9099 - C, Page 3... Staff did not prevent resident from eloping. According to the RP, a resident in room number 409 had eloped from the building and was found on the ground in the parking lot located in the front of the facility. LPA Valerio requested resident information for the resident who was present in 2023. According to Executive Director Alex, Resident 7 (R7) occupied the room 2023. Based on records review, R7 did not have a documented elopement in 2023. Staff are not meeting residents’ hygiene care needs. According to the RP, R7 did not receive a shower after being found outside on the ground. According to Ed Alex, the facility does not document whether a shower was given or not. Residents are provided a shower schedule, if they receive assistance from staff. If a staff member does not get to the resident's shower or the resident refuses to shower for the day, there would not be a document for review. Staff are not providing adequate laundry service for residents. According to the RP, the facility allegedly did not provide residents with clean clothing. According to an interview with Staff 1 (S1), S1 does not recall any issues with laundry or laundry machines during 2023. According to an interview with R5, R5 had no complaints for the facility, always has clean item to wear, and stated housekeeping is at the facility every day. Staff are not providing adequate food service for residents. According to the RP, the facility did not have enough staff resulting in residents not getting their meals. On 07/05/23, it was alleged that meal service took so long that residents left the dining room without eating. According to an interview with staff, staff stated service staff are separate from clinical staff. If there are any shortages with service staff, there are multiple back-ups, such as on-call servers or any administrative or management staff that would be able to provide service. Interviews with staff also indicate that they never observed any shortage of wait staff and to their knowledge every resident received their food. Based on interviews with six (6) resident interviews, 6 out 6 resident interviews stated that food had always been delivered on time, have never received cold food, or did not have any issues with the food at the facility. Continues on LIC 9099 - C, Page 4... Staff are not properly treating facility for pests. According to the RP, the facility is alleging that the facility had rodents in the kitchen and left it untreated, which contributed to a norovirus outbreak in 2023. Based on review of facility records, the facility contracted pest control services through EcoLab. The facility provided copies of services provided on 07/05/23, 07/12/23, 07/13/23, 07/25/23, 08/15/23, 08/24/23, 09/14/23, and 09/20/23. All services, which included inspections and placement of traps, addressed rodent issues throughout the facility . Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, and therefore the allegations are unsubstantiated. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. An exit interview was held, and a copy of report was left at the facility.the state’s words, verbatim · CDSS document, Dec 21, 2024 · control 26-AS-20230706110045

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(6) · Plan of correction due date: Jan 20, 2025

87465 Incidental Medical and Dental Care(a)... (6)... a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement was not met as evidenced by: Based on records review, the licensee did not ensure staff maintained a complete medication record for R4 and R5 medication dosages, which poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 21, 2024

Plan of correction: Licensee stated Administrator will send a copy of in-service training held with staff by POC due date.

Allegation investigated: Staff did not have adequate record keeping for a resident

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to deliver complaint investigation findings. LPA Valerio met with Executive Director (ED) Alex Baiasu, and explained the purpose of the visit. The department has determined the following as it relates to the aforementioned allegation. The investigation consisted of interviews with facility staff and records review of facility records. The reporting party alleged that the facility did not keep adequate records for Resident 1 (R1), which led to the R1 to fall behind on monthly payments and eventually evicted from the facility. According to Staff 1 (S1) , R1 had a personal service rate that increased when R1 needed additional services. S1 explained that a nurse conducts an assessment with the resident and input information into their system, which generates the personalized plan and cost. According to S1, there is always a conversation with the resident and/or resident's responsible party. If a resident does not get to do the signing, a discussion will be done. S1 stated the facility was very transparent with R1 regarding services. Substantiated Continued from LIC 9099 According to Staff 2 (S2), R1's personalized service plan does not have a signature but they had a discussion with R1 verbally. For R1, the facility did not have her sign the updated plan(s). S2 was unsure if the resident refusal was documented. S2 reported that R1 did not want to sign it. R1 was considered responsible for self and therefore, no other person would be able to sign on behalf of R1. S2 reported that when S2 started in 2022, R1 had an outstanding balance with the facility. S2 reported that the facility did not have a checklist of services that are provided every day and instead have shift notes from employees. S2 stated the facility was not documenting refusal of services on progress notes. According to Staff 3 (S3), the facility provides different discounts to residents based on executive directors discretion and if a resident qualifies. If a resident qualifies for a discount rate or credit to their monthly bill, it be documented on their invoice. S3 reported that if a resident has a "Personal Solutions" charge on their monthly invoice, it is due to a resident had a delivery of supplies such as wipes, briefs, etc. On 09/01/2023, the facility provided documents to Community Care Licensing. Documents included R1's invoices from 2013-2024, R1's Personal Service Plan dated 04/05/2023, Personal Service Plan dated 02/09/2023, Personal Service Plan dated 08/03/2022, R1's 30 Day Eviction Notice dated 05/2023, R1's progress notes dated 09/10/2022 - 11/23/2022, R1's Admission Agreement dated 12/2012, Rental Increase Notification 10/25/2013, and R1's Addendum to Residency Agreement dated 01/02/2013. During LPA Valerio's review of R1's documents, LPA Valerio observed multiple inconsistencies with invoice charges, invoice credits, and documentation/proof of R1 being properly charged for services being received. LPA Valerio observed R1 to have an yearly increase for the Basic Service Rate every year from 2012 until 2024. LPA observed a signed document by the resident and facility for the increase in the Basic Service Rate for 2012, 2013, and 2014. From 2015 until 2024, there was no documentation provided to show the facility and the resident had a discussion or was made aware of the yearly increase. Continues on LIC 9099 - C, Page 3... LPA Valerio observed an invoice dated 01/16/2023. The invoice had multiple Personal Service Rate (PSR) Charges for earlier months, 09/02/2022 - 02/282023. For 09/22 the PSR was charged as $1,930.24 on the 01/16/2024 invoice. Previously, R1's invoice dated 09/02/2022 was initially charged $193.00 for the PSR. For 10/2022 until 02/28/2023, the PSR was charge for $2,030.00. LPA Valerio observed invoices for 09/2022 to 02/2023. LPA observed the PSR was incorrectly charged to the resident during those months. According to R1's Personal Plan dated 04/04/2023, the net PSR totaled to $193.00. LPA Valerio did not observe a Personal Service Plan that stated the net PSR totaled to $1, 930.24. However, LPA Valerio observed a Personal Service Plan dated 02/09/2023 that stated the net PSR totaled to $2,223.00. LPA Valerio observed another Personal Service Plan dated 08/03/2022 that stated the Net PSR totaled to $2,223.00. These documents did not have signatures from a facility representative, R1, or any responsible party for R1. LPA Valerio observed R1's invoices to have a charge for Personal Solutions; however, the facility did not provide a signed document showing the resident received additional services or requested the additional services. Based on records review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC-9099D. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. An exit interview was conducted, and a copy of the report was left at the facility Continued from LIC 9099 - A LPA Valerio provided Technical Assistance to current Executive Director Alex regarding the situation and informed current ED that R1's scenario would not be considered a discharge and still considered an eviction. If a resident were to be given a 3-Day Notice Eviction, Community Care Licensing would need to approve the eviction prior to it being issued to the resident. Reference: Title 22, Section 87224 and H&S 1569.682(a)(2)(A) through (F) LPA Valerio reviewed R1's invoices from 2013 until 2024. LPA observed R1's less payments started in June of 2019 when R1 missed a payment. R1 made two payments for July of 2019; however, the amount was short $1,620. In addition to inconsistencies with the facility's account management of R1's services, the trend of paying below the total amount due continued until 2024. Based on the review of R1's invoices, it is unclear whether the less payments were due to the resident unable to make payments or the inconsistent service charges from the facility. According to the eviction notice dated 05/05/2023, the facility based their eviction off failure to pay sums due for months 09/01/2022 until 04/01/2023. Based on records review, R1 was in rehab for three (3) months and charged for monthly services. According to S2, Their admission agreement states that even if a resident is in rehab they continue payments, and therefore, the charges were warranted. However, the facility worked with R1 and credited the amount for the time R1 was in rehab. R1 was also admitted back to the facility after being in rehab. According to R1's sign admission agreement, the following is stated: Fees during Absence: "If you are absent from the Community for any reason, such as, for a hospitalization, vacation, temporary nursing home care or rehabilitation, the Residency Agreement will remain effective and you will be charged the full Monthly Service Rate. There will be no reduction in the Meal Service Program until resident is absent from the Facility for thirty (30) continuous days. If you provide written notice of your intent to terminate the Agreement pursuant to Section IV, termination will be effective and charges will cease the later of the end of any applicable notice period or the removal of all of your personal belongings." Continues on LIC 9099 - C, page 3... LPA Dolores attempted to obtained records regarding R1's case with law enforcement. LPA Dolores attempted to obtain records two times. Due to the case being open, the documentation could not be released; therefore, LPA Dolores was unable to obtain documentation. Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, and therefore the allegations are unsubstantiated. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. An exit interview was held, and a copy of report was left at the facility.the state’s words, verbatim · CDSS document, Dec 21, 2024 · control 26-AS-20230823123127

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Jan 20, 2025

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility… This requirement was not met as evidenced by: Based on staff interviews and records review, the licensee did not ensure staff properly documented R1's monthly service charges, increase in BSR, increase in PSR, additional service charges, and discussions with R1 regarding said charges. This poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 21, 2024

Plan of correction: Licensee stated the Administator will send current procedure for maintaining rental increase, service increase rates, etc. LPA Valerio to receive documents by POC due date.

Allegation investigated: Facility staff are not responding to resident's call system in a timely manner. Facility does not have sufficient staff to meet the needs of residents. Facility staff are not ensuring that resident’s colostomy care is being addressed.

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to deliver complaint investigation findings. LPA Valerio met with Executive Director (ED) Alex Baiasu, and explained the purpose of the visit. The following has been determined as it relates to the aforementioned allegations. The investigation consisted of resident interviews, staff interviews, and records review. According to the Reporting Party (RP), the facility does not respond to call lights in a timely manner due to short staffing. There was an incident with Resident 1 (R1) where R1''s colostomy bag exploded because staff did not change the bag. Continues on LIC 9099 - C.. Unsubstantiated LPA Valerio reviewed progress notes for R1. R1 was admitted to the facility on 11/24/23. During admission, the staff on shift notes that R1's Colostomy bag was leaking. The staff emptied and replaced the bag. According to the staff, the staff educated family and caregiver on emptying colostomy bag and advised to call nurse for assistance when needed. Based on R1's records, R1 had home health services, which included visiting nurses for nephrostomy care. R1 was sent to the hospital by the facility on 11/25/23 at 5:30 AM due to R1's family member observing the bag to explode and the family member did not have supplies to change it. R1 did not return to the facility and was only at the facility for less than 24 hours. According to an interview with Staff 1 (S1) the facility call logs are not available past 6 months. Anything before that the third party contractor may or may not be able to retrieve the information. According to the RP, Resident 2 (R2) had been reporting rats being seen and although facility maintenance staff put a rat trap in the room, R2 attempted to catch the mouse, which resulted in a fall. According to the RP, the facility failed to respond to R2 call for help. LPA Valerio reviewed facility records for R2. R2 was observed to have a fall on 11/14/2023. R2 was found by staff after they heard a loud thump. R2 stated, "I was trying to catch the mouse in my apartment, lost my balance, and fell back dropping the cat food. While falling down I hit my head on the floor and landed on my right wrist." Facility staff immediately contacted 911, checked resident vitals, and was sent to the hospital shortly after. Based on records review, the residents current assessment now have a fall risk in place. The latest assessment was conducted on 10/04/2024. According to an interview with Resident 3 (R3), R3 feels that staff have always been attentive to their needs. R3 cannot recall how last year (2023) was entirely but nothing came to mind. R3 reports that there are many staff that are working all the time. According to an interview with Resident 4 (R4), R4 likes living at the facility and has been at the facility for thirteen years. R4 reported staff assist resident when R4 needs assistance with toileting. Anytime R4 calls for help, staff are there to assist R4. Continues on LIC 9099 -C... On 01/04/2024, this report was amended to remove irrelevant information and confidential pronouns. LPA Valerio reviewed the December Staff Schedule for 2023. LPA observed the facility scheduled a minimum of two Medication Technician (MT)s and three Caregivers (CG) for AM shift (6:00 AM - 2:00 PM) and PM Shift (2:00 PM - 10:00 PM). During overnight shift, there was one MT and two CG scheduled. LPA observed that on 12/04/23 and 12/05/23, there was a call out and therefore only two caregivers were on shift for the PM shift. On 12/09/23, the facility had two caregivers call out that day and therefore, there was only one CG on shift along with two MTs. On 12/13/2023, LPA observed one CG staff call out leaving only two MTs and two CGs on shift for the AM shift. For the week of 12/17 - 12/23, the facility had scheduled a minimum of two MT and three CG on all shifts. On 12/24/2023 and 12/23/2023, they had scheduled an extra LVN and caregiver for this shift, which left the facility with three MTs and four CGs during PM shift. For 12/23/23 - 12/31/23, LPA Valerio two MT and three CG on each shift for AM. For PM shift, they scheduled three MT and three CG. Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, and therefore the allegations are unsubstantiated. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. An exit interview was held, and a copy of report was left at the facility.the state’s words, verbatim · CDSS document, Dec 21, 2024 · control 26-AS-20231222164321

Type of visit: Case Management - Incident

Licensing Program Analysts (LPAs) David Marrufo and Marcella Tarin conducted an unannounced Case Management visit and met with Administrator (ADM) Alex Baiasu. The purpose of the visit was to conduct a follow-up visit for two SOC341 Suspected Adult/Elderly Abuse forms that were submitted by the facility to the Department on 09/09/2024. The first SOC341 form was for resident R1, who reported to facility staff that $300 in cash and two necklaces belonging to R1 had been stolen. The second SOC341 stated that R2 reported to staff that a necklace valued at $2000 and two earrings valued at $500 belonging to R2 had been stolen. During visit, LPAs interviewed ADM, who stated that staff S1 had been under investigation by local law enforcement for thefts occurring outside of the facility. ADM played a voicemail left on ADMs phone by someone identifying himself/herself as local law enforcement and stated that the investigation into a staff member of ADM's facility for a theft of a house had named the staff as a suspect. The law enforcement officer stated in the voicemail that law enforcement could not prove that the staff stole items from the house. ADM stated that law enforcement had arrived to the facility at an earlier date and confiscated S1's telephone. ADM stated that S1 reported during interview with ADM that S1 had visited the facility outside of S1's working hours and had established friendships with family members of residents. ADM stated S1 told ADM that S1 spends time with family members of residents outside of the facility. ADM stated to have not submitted LIC624 Unusual Incident/Injury Reports for the reported thefts of R1 and R2's belongings. See LIC809-C for more information. Page 1 of 2. During visit, LPAs obtained a copy of the Suspension Form issued to S1. The form is dated 10/04/2024 and is signed by R1 and ADM. The form states S1 is being placed on suspension pending an investigation into allegations of theft. During visit, LPA Marrufo interviewed resident R1. During interview, R1 stated to have found R1's necklace in a dresser drawer, but was still missing R1's $300. ADM stated during interview that R1 reported to ADM that R1 reported to have found the $300. ADM stated during visit that R2 had left the facility with a family member today. During visit, LPA Marrufo interviewed staff S2 and S3. S2 stated to have not observed or heard of any reports of any resident items being missing or stolen. S3 stated that R2 reported to S3 to have found R2's missing necklace and to have had misplaced it. S3 stated to have observed R2 wearing the necklace. During visit, LPAs obtained copies of R1 and R2's Identification and Emergency Information Forms. LPAs obtained copies of R1 and R2's Safeguard for Property and Valuables Forms. Both R1 and R2's Safeguard for Property Valuables forms claimed no items. During visit, LPA observed the Theft and Loss Policy posted in the facility lobby area. Advisory Notes were issued. See LIC9102 pages for more information. No deficiencies were cited as per California Code of Regulations Title 22. This report was reviewed with ADM Alex Baiasu and a copy of this report was provided. Page 2 of 2. END REPORTthe state’s words, verbatim · CDSS document, Dec 11, 2024

Allegation investigated: A non-medical skilled professional is administering insulin injections to diabetic residents. Staff are not administering residents’ insulin as prescribed.

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation findings and met with Executive Director (ED) Alex Balasu. On 2/12/2024, the Department received a complaint with the above allegations. On 2/22/2024, the Department conducted an initial investigation visit. LPA interviewed ED, 3 staff, and 4 residents. LPA requested roster of residents, LIC500, resident physician reports, Medication administration records, centrally stored medication log, resident assessment, and physician orders. Continue on LIC9099-C. Page 1 of 4. Unsubstantiated A non-medical skilled professional is administering insulin injections to diabetic residents: The allegation is that a staff who is not a nurse and administers insulin injection to resident. On 2/22/2024, LPA interviewed previous Executive Director (PED). PED stated he/she just started to work for the facility in January 2024. PED stated the facility checks the nurse license when the facility hires nurse and the facility nurse should maintain the valid nurse license. PED printed out the evidence of staff S1 and S2's nurse licenses. ED stated if residents can inject insulin by themselves, then Med Techs or nurses deliver the insulin and the residents inject the insulin by themselves. PED stated if the residents cannot inject insulin by themselves, then the facility nurses deliver the insulin and inject insulin for residents. PED stated only facility nurses can inject insulin for residents, caregivers and Med Techs were not allowed to inject insulin for residents. LPA interviewed staff S2. S2 stated the facility checked his/her LVN license before the facility hired him/her. S2 stated Med Techs and facility nurses deliver medications to residents, but only the facility nurses deliver and inject insulin for residents. S2 stated he/she checked the computer for residents' prescription. S2 stated he/she usually deliver and inject the fast-acting insulin 30 minutes before the meals and one and half hours before bedtime for the long-acting insulin. S2 stated he/she follows the doctor orders which specifies exactly what to administer insulin to residents.. LPA interviewed 2 Med Techs. 2 Out of 2 Med Techs stated they don't conduct the insulin injection for residents. LPA interviewed 4 residents (R1 - R4). 2 Out of 4 residents stated they don't have insulin injection. Resident R1 stated only facility nurses conducted insulin injection for him/her. R1 stated staff S1 and S2 conducted insulin injection for him/her. Resident R2 stated only facility nurses conducted insulin injection for him/her. R2 was unable to remember the names of the facility nurses. On 9/27/2024, LPA interviewed staff S1. S1 stated he/she was in nursing school and had the permit to do the duty of facility nurse when shadowed with other facility nurses. S1 stated he/she will have LVN license next month. S1 stated he/she submitted his/her permit to the facility. S1 stated he/she only did insulin injection with nurses. Continue on LIC9099-C. Page 2 of 4. Based on the review of R1 and R2's physician report, R1 and R2 are unable to conduct injection by themselves. Based on the checking of the S1's nurse license document, S1's LVN license was issued on 10/22/2024. Staff are not administering residents’ insulin as prescribed: The allegation is that resident R1 and R2 have been times residents have not received their insulin. On 2/22/2024, LPA interviewed previous Executive Director (PED). PED stated the facility administer insulin to residents based on doctor prescription/order. LPA interviewed staff S2. S2 stated the facility nurses deliver insulin to residents. S2 stated if residents are able to inject insulin self then residents inject insulin by self, if residents unable to inject insulin by self then nurses inject insulin for the residents. S2 stated he/she delivers/injects insulin based on the doctor prescription in the computer system. S2 stated usually he/she delivers/injects short acting insulin 30 minutes before meals and long acting insulin one and half hours before bed time for residents. S2 stated she always sticks to doctor prescription/orders to administer insulin to residents.. LPA interviewed resident R1 and R2. Both stated they did not have experience of medication error or missing medication incidents. Based on the review of R1 and R2 Medication Administration Records (MAR) in January 2024 and February 2024, there are some entries were observed missing insulin injections for R1. PED and staff S2 explained the empty entries were due to computer error and staff were unable to enter data in the computer MAR system. Continue On LIC9099-C. Page 3 of 4. Based on documents reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegation did or did not occur. No citations noted for today’s visit. Exit interview was conducted with ED. A copy of this report was provided to ED. Page 4 of 4.the state’s words, verbatim · CDSS document, Dec 6, 2024 · control 26-AS-20240212124552

Allegation investigated: Resident was handled in a rough manner while in care. Resident was spoken to in an inappropriate manner while in care. Medical attention was not sought for a resident in a timely manner.

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to the facility to deliver complaint investigation findings. LPA Valerio met with facility front desk staff, and explained the purpose of the visit. LPA was later met by Executive Director Alex Baiasu. The following has been determined as it relates to the aforementioned allegations. On 0705/22, the Reporting Party (RP) stated an incident occurred a week on 06/24/22 prior involving an unnamed resident and a staff member. The alleged staff member, who worked for Cebu Staffing Agency, was assisting a resident with showering and applying a cream. The staff member was very rough with the resident and caused a skin tear while applying the cream. During this time, it was reported the alleged staff member told the resident they were fat and needed to walk. Continues on LIC 9099 - C... Unsubstantiated Continued from LIC 9099 CCL attempted to interview the RP on 07/05/22, 07/12/22, 08/02/2024, and 10/12/2024. All attempted were unsuccessful. According to an interview with Staff 3 (S3), S3 reported working during 2022. S3 reported recalling residents Complaining about the third party agency staff. There was internal investigation, but is unaware of the outcome. The incident described by S3 was similar to the information provided by the RP. Those who received a complaint, did not return to work. According to an interview with Staff 5 (S5), S5 stated the facility no longer uses Cebu Staffing agency. S5 is unaware of the incident. S5 stated the Wellness Director in 2022 is no longer working for Brookdale Scotts Valley. According to the RP, the incident was reported by the RP to the Health and Wellness Director; however, the resident's wounds were not address until 06/28/2022. According to an interview with Resident 1 (R1), R1 recalled a caregiver was rushing to help R1 when R1 first moved into the facility in 2022. R1 reported the staff was putting cream on R1's stomach area really hard and fast, which made R1 bleed. The skin tear was about three inches. R1 was given first aid a few days later. R1 did not recall the name, but could recall the race of the individual. R1 recalls never seeing the staff after R1 told the front desk. R1 said the staff was also the person to say R1 was fat and needed to walk up and down the hallway. According to R1's LIC 601 dated 10/22/2021, R1 was able to administrator own prescription medications, injections, glucose testing, PRN medications, and store own medications. According to an interview with Staff 7 (S7), S7 reported R1 was not on medication management during 2022; therefore, staff nor the facility have record of the medications provided to R1. Continued from LIC 9099 - C, page 2 On 10/18/2024, LPA Valerio requested staff records and call button logs for June 2022. Due to the amount of time since the initial opening of the complaint, the facility needed to contact vendors for data from two years ago. Due to the above noted information, although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, and therefore the allegations are unsubstantiated. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. An exit interview was held and a copy of report was left at the facility with ED Alex Baiasu.the state’s words, verbatim · CDSS document, Nov 9, 2024 · control 26-AS-20220705084955

Allegation investigated: Resident's room has pests. Resident was threatened by other residents while in care. Resident was threatened by staff while in care.

Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to deliver complaint investigation findings. LPA Valerio met with Executive Director Alex Baiasu, and explained the purpose of the visit. The Department has determined the following as it relates the above mentioned allegations. Resident's room has pest The Reporting Party (RP) alleged that there were reports of ants on a resident's bed in June of 2022. Due to short staffing, the work orders for the ants were not addressed. Continues on LIC 9099 - C... Unsubstantiated Continues from LIC 9099... Based on facility documentation, the facility contracted with pest control services, Ecolab Pest. LPA observed Ecolab Pest serviced the facility on 05/11/22, 06/08/22, and 07/25/22. All services noted, "No ant activity…No cockroach activity was noted during the inspection and/or service." and "Preformed interior rodent service, checked and reset all traps." Based on staff interviews, the facility has utilized Eco Lab Pest Services for years. On 10/19/2023, the facility provided Community Care Licensing (CCL) a copy of a work order for a resident room. There were 4 pages of work order entries. Each work order was put in by staff for multiple tasks including: brake of wheel chair not working, clean carpet, blinds, roaches in kitchen, phone not working, door battery replacement, etc. LPA Valerio observed the dates were not displayed for each work orders but the work order ranged from 2020 until 2023. The work orders for the roaches did not indicate the date; however, it was noted that the work order was assigned to a specific maintenance person. An interview was conducted on 08/02/2024 with Resident 1 (R1). R1 has lived in the community since 2021. R1 reported that there no pest issue. There were ants on R1's bed and these little black bugs mites. R1 believed they were beadles and the facility got rid of them. The facility got a complaint from staff that they saw these bugs in the dining room area. Afterwards, the dining shut down from fumigation. The interview conducted with R1 did not indicate the year of the occurrences. According to an interview with Resident 2 (R2). R2 has not observed any ant on the bed. R2 has lived in the community for seven (7) years. Resident was threatened by other residents while in care. The RP reported that the RP observed Resident 4 (R4) getting yelled at by other residents and received threats from the residents. The residents did not appreciate that R4 was discussing religious information in the dining room. Continues on LIC 9099 - C, Page 3... Continued from LIC 9099 - C, page 2 CCL attempted to interview the RP on 07/05/22, 07/12/22, 08/02/2024, and 10/12/2024. All attempted were unsuccessful. LPA Valerio learned that R1 passed away in 2022. Therefore, an interview with R1 concluded to be unsuccessful. An interview was conducted with Resident 2 (R2) on 08/02/2024. R2 was good friends with R1. R2 indicated R1 was not aware of any residents yelling or threatening R1. R2 did not observe R1 being yelled at or threatened by residents. R1 liked to read the bible. An interview was conducted with Staff 1 (S1) on 08/02/2024. According to S1, R1 read R1's bible out loud which tended to irritate some individuals. S1 reported some resident would say “take [R1] out of here”. The staff would intervene to the resident nicely. S1 did not report observing any threats to R1. An interview was conducted with Staff 2 (S2) on 08/02/2024. According to S2, R1 would read the bible in the dining room. The residents that didn’t like it would tell him to shut up and call staff to complain about it. An interview was conducted with Staff 3 (S3) on 08/02/2024. According to S3, S3 remembers R1 reading the bible in the dining room every day. It was R1's mission in life. R1 was hard of hearing and to communicate people had to yell at him. S3 reported residents would constantly yell at R1 and say to get the hell out of here. Staff would offer another room for R1 to carry about R1's bible readings. An interview was conducted with Staff 6 (S6) on 10/12/2024. According to S6, R1 was a wonderful and kind person. Other residents would say "Get the f out here" but it was not observed to be threats towards R1. When that would happen, staff would take R1 out of the dining room, and offer R1 another common area for R1 to be in. Some residents do not like to hear about God, especially if they are not religious. R1 would be very loud to the point where you could hear R1 from the lobby area. Continues on LIC 9099 - C, page 4 Continued from LIC 9099-C, page 3 Resident was threatened by staff while in care. According to the RP, the RP stated Executive Director (ED) Dimple Kamar threatened that R1 would be banned from the dining room in 2022 due to R1's speaking out loud about his religion. LPA Valerio learned that ED Dimple Kamar has not been the ED for some time; therefore, an interview with him is deemed unsuccessful. According to interviews with R1 and R2, they do not recall R1 ever being banned from the dining hall. R2 reported that staff are respectful. According to interviews with S1, S2, S3, S4, and S5, R1 was never banned from the dining hall and the facility would never have implemented this plan. Due to the above noted information, although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, and therefore the allegations are unsubstantiated. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. An exit interview was held and a copy of report was left at the facility with ED Alex Baiasu.the state’s words, verbatim · CDSS document, Oct 13, 2024 · control 26-AS-20220705084955

Allegation investigated: Staff did not give resident's records to resident's responsible party. Staff did not follow resident's care plan. Staff did not give resident sufficient notice of rate and services increases.

On 8/16/2024 , Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Executive Director Alex Baisu and explained the purpose of today's visit. Regarding the allegation of Staff did not give resident's records to resident's responsible party, reporting party (POA1) stated that on March 20, 2023, POA1 requested residents' (R1) medical records and medication to be delivered on move out day. Only R1s medications were handed over after a second request at the facility, and no medical records were ever given. The Department received a copy of the email sent from POA1 to the facility Administrator at the time (ADM1) on 05/13/2023 stating POA1 requests to have the facility provide R1’s records to POA1 on 05/20/2023, the date POA1 was planning to move R1 out of the facility. page 1 of 3 Substantiated POA1 stated to have visited the facility on 05/20/2023 and requested R1’s records, but did not receive them. POA1 sent an email to staff S1 on 06/09/2023 stating to have visited the facility on 05/20/2023 and one two other later visits and had not been given R1’s records. The Department received a copy of the letter POA1 sent to the facility requesting R1’s records on 06/21/2023. POA1 provided the Department a copy of a screenshot of a text message from facility (ADM1) dated 06/26/2023 stating that ADM1 received POA1’s letter. The Department obtained a photograph of the mail package label addressed to POA1 from the facility address. The mail package label states the package was sent via Priority Mail on 07/17/2023 and arrived on 07/19/2023. During interview on 07/20/2023, POA1 stated to have received R1’s records via mail on 07/20/2023. Regarding the allegation of Staff did not follow resident's care plan, POA1 reported that facility wasn't able to get R1 ready for a doctor’s appointment and no one had been there and R1 was still in a robe and no one had taken care of R1. The Department obtained a copy of R1’s Residency Agreement. The Basic Services section of the Residency Agreement states, “A. BASIC SERVICES. “In order to provide you with care, supervision and assistance with instrumental activities of daily living in order to meet your needs, we will provide you with the following Basic Services…Transportation – We will make available scheduled transportation services as set forth in the Addendum to the Residency Agreement…Assistance with Access to Outside Services – Community will assist you with arranging needed appointments with professionals offering medical, dental, and other health care services.” R1‘s Personal Service Plan states R1 has a preferred AM wake and care times of between 7:30 AM and 8:30 AM and R1 needs assistance with sicks and leg wraps, with AM/PM dressing and undressing, and with back brace. Page 2 of 3 The Department obtained a copy of an email sent from ADM1 to POA1 on 05/13/2023. In the email, ADM states, “There was a hiccup one day that caregiver did not get R1 ready in time for R1’s appointment.” Regarding the allegation of staff did not give resident sufficient notice of rate and services increases. POA1 stated that R1 was charged an extra $3300. They said they did an assessment and said with the extra assistance R1 needed with showering and getting dressed, they were going to charge $3300. Based on records review, R1s resident agreement states that, on page 7-8, Rate Changes, "We will provide (60) days written notice of any change in the rates for Basic Services, Personal Services, Select Services, Therapeutic Services or any other fees listed in this agreement. Additionally, we may offer or require a change in the Personal Service Plan when we determine additional services are requested or required. When such a change in services occurs and alters your Personal Service Plan, the associated fees as referenced notice of change in Exhibit A and detailed in Exhibit Z, will be charged to you immediately after written notice of change in services is provided. According to POA1, there was no written notice provided before the increase was applied. Therefore, based on interviews and records review and information collected, the above allegations are 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. A copy of this report and the Appeal Rights are provided. page 3 of 3the state’s words, verbatim · CDSS document, Aug 16, 2024 · control 26-AS-20230711095753

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Aug 17, 2024

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility...(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This was not met as evidenced by: Based on interviews and records review, R1 was not ready in time for a doctors appointment which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 16, 2024

Plan of correction: Licensee to submit a plan to address the needs of residents in care. Licensee to submit to LPA by POC deadline.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(19) · Plan of correction due date: Aug 23, 2024

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1,... residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (19)To have prompt access to review all of their records ... Photocopied records shall be provided within two (2) business days... This requirement was not met as evidenced by: Based on interviews and records review, The Licensee did not ensure that resident R1’s records were provided within two business days to R1’s Power of Attorney, which poses a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 16, 2024

Plan of correction: Licensee to submit a plan to address how the facility will comply to records requests from responsible parties. Licensee to submit to LPA by POC deadline.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(g)(4)(B) · Plan of correction due date: Aug 23, 2024

87507 Admission Agreements (g) Admission agreements shall specify the following: (4) Modification conditions, including the requirement for the provision of at least 60 days prior written notice...(B)The conditions under which a licensee may increase or change rates shall be specified in the admission agreement, pursuant to Health and Safety Code sections 1569.655 and 1569.657. This was not met as evidenced by: Based on interviews and records review, the Licensee did not provide prior written notice to R1 regarding the increase of rates for care provided which poses a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 16, 2024

Plan of correction: Licensee to submit a plan to address how the facility will comply to providing notices to responsible parties regarding increases in rates. Licensee to submit to LPA by POC deadline.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Simi Rai and Marcella Tarin conducted an unannounced Required 1 Year visit. LPAs met with Administrator Alex Baiasu and stated the purpose of today's visit. During visit, LPAs toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPAs Rai and Tarin toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas. LPAs observed additional food supply areas and secured areas for cleaning supplies and laundry detergents. LPAs toured at random 10 resident bedrooms. 10 out of 10 resident bedrooms had available bedding, drawers, and functioning lights. The facility bathroom had available soap, paper towels, and trash cans with lids. The water temperature in the bathroom sinks ranged from between 110 degrees F and 117.1 degrees F. Fire extinguisher was observed and inspected on 12/05/2023. Facility smoke detectors, carbon monoxide detectors and sprinklers were inspected by a third party vendor on 08/05/2024 and passed inspection. The last disaster drill were conducted on 07/26/2024. LPAs reviewed facility records for 10 staff and 10 residents. LPAs reviewed S1 staff file and observed S1 did not have a California Criminal Record Clearance. Administrator stated S1 did not obtain a California Criminal Record Clearance after turning 18 years of age in June 2024. Administrator will ensure S1 obtains a California Criminal Record Clearance before returning to work. Continuation on LIC809-C, Page 1 out of 2. Page 2 out of 2. Deficiencies were cited per California Code of Regulations, Title 22. Technical Violation were provided during visit. A civil penalty is being assessed for the amount of $500. For S1 working in the facility for more than 5 days without obtaining a California criminal record clearance, the civil penalty will be for $500 ($100 per day x 5 days = $500). See LIC421BG. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Administrator Alex Baiasu and a copy of the report was provided. Appeal Rights was provided.the state’s words, verbatim · CDSS document, Aug 15, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Aug 16, 2024

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review... shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department This requirement is not met as evidenced by: Based on record review and interview, staff S1 did not have a California Criminal Record Clearance and ADM stated S1 did not obtain a Criminal Record Clearance after turning 18 years of age which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 15, 2024

Plan of correction: Administrator stated to submit a written plan of action understanding regulation and will ensure staff obtain a California Criminal Record Clearance prior to working at the facility. Administrator will ensure staff S1 obtains a California Criminal Record Clearance by POC due date. Administrator agreed and understood.

Type of visit: Office

On August 13, 2024, the Department conducted an informal meeting with Administrator (ADM) Alex Baiasu and District Director of Operations Grace Ndomo, in Community Care Licensing office, to further discuss the incident regarding physiological abuse which was reported to Community Care Licensing on April 30, 2024. A Subsequent Case Management visit was conducted on May 3, 2024. LPA and LPM requested the facility ADM provide an action plan to discuss the following: Training regarding personal rights for all staff, from an outside vendor. How facility staff will handle residents with MCI (Mild Cognitive Impairment). How the facility will respect the residents personal rights Reassessing residents to ensure, residents with MCI needs are being met. ADM stated he will send the action plan by August 27, 2024. LPA and LPM also discussed the use of surveillance camera's in the facility. LPA and LPM informed ADM the facility will have more frequent monitoring as well. This Report was reviewed with ADM Alex Baiasu and a copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 13, 2024

Allegation investigated: Staff do not ensure that resident's needs are met Staff do not safeguard resident's personal items

Licensing Program Analysts (LPAs) Christine Dolores and Marcella Tarin conducted an unannounced complaint investigation to deliver the findings on the above allegations. LPAs met with Executive Director Alex Baisu. On July 5, 2024, the Department received a complaint alleging Staff do not ensure that resident's needs are met. It has been alleged that residents are missing their showers. On July 10, 2024, LPA Monter interviewed staff S1-S6. 5 Out of 6 staff interviewed stated residents are being given showers. 6 Out of 6 staff interviewed stated staff will assist residents with their showers if a resident asks for help. S4 stated the shower schedule is very disorganized and residents have missed their showers. Staff S4 and S5 stated residents might request a different time for their shower, which throws off the schedule later that same day. S5 stated staff might not complete the showers at the exact time scheduled, but staff will ensure its completed by the end of the shift. PAGE 1 OF 2. Unsubstantiated LPA Monter interviewed residents R1-R9. R1 stated the facility has missed giving him/her a shower. R1 stated when staff doesn’t arrive for his/her scheduled shower, he/she will contact staff, then staff will assist him/her. 2 Out of 9 residents interviewed (R3 & R8), stated they don’t need assistance with showering. 4 Out of 9 residents interviewed (R4-R7) stated they receive their showers, and the facility hasn’t missed giving his/her shower. Resident R2 and R9 were unavailable to be interviewed. On July 5, 2024, the Department received a complaint alleging Staff do not safeguard resident's personal items. It has been alleged that resident’s laundry has been lost. On July 10, 2024, LPA Monter interviewed staff S1-S6. Staff S1 stated the facility has a schedule for laundry service and each resident has their own bins. S1 S2 S3 S5 stated they put the residents’ cloths in the washer, and note it on the board, with the resident’s room number to keep track of their cloths. S1 S2 S5 stated the residents’ cloths has not been lost. S3 S4 S6 stated if a resident reports something lost, then the facility will replace the lost item or reimburse the resident. LPA interviewed residents R1-R9. R1 stated the facility has lost some of his/her cloths but once he/she informs the staff, they find the missing clothing. 4 Out of 9 residents’ interview (R3, R5-R7) stated they have not had any clothing lost. Residents R4 and R8 stated they do not use the facility laundry service. Resident R2 and R9 were unavailable to be interviewed. Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. This report was reviewed with Executive Director Alex Baisu and Valentine Mathangani, Health & Wellness Director III a copy of the report was provided. PAGE 2 OF 2. LPA Monter interviewed residents R1-R9. Resident R1 and R3-R8 stated the facility does have an outbreak of covid. Resident R1 and R3-R7, stated the dining room is currently closed and meals are being delivered to the resident’s room. Resident R4-R5, R9 stated the facility is offering residents masks. Resident R2 and R9 were unavailable to be interviewed. LPA Monter interviewed Witness W1. W1 stated there is currently a covid outbreak at the facility. W1 stated the dinning room is closed due to the covid outbreak. LPA Monter toured the facility. LPA observed the dining room as closed. LPA observed the facility delivering residents lunch to residents’ bedroom. LPA observed facility staff wearing masks. On July 5, 2024, the Department received a complaint alleging Staff handled resident in a rough manner. It has been alleged that resident R1 was pushed. On July 10, 2024, LPA Monter interviewed staff members S1-S6. 6 Out of 6 staff interviewed denied the allegation and stated staff members don’t push residents. 6 Out of 6 staff members interviewed stated staff did not push R1. LPA Monter interviewed residents R1-R9. R1 stated he/she has never been pushed by staff. Resident R3-R8 stated they have not seen staff pushing residents. Resident R2 and R9 were unavailable to be interviewed. LPA Monter interviewed Witness W1. W1 stated he/she has never seen staff handle residents roughly or seen staff push residents. On July 5, 2024, the Department received a complaint alleging Staff do not treat resident with dignity or respect. It has been alleged R1 was left at the dinning room table for an extended period of time. PAGE 2 OF 3. On July 10, 2024, LPA Monter interviewed staff members S1-S6. Staff S1-S3, S5-S6, stated residents have not been left unattended in the dinning room for an extending period of time. S4 stated he/she has seen R1 left unattended. S4 stated staff don’t want to escort R1 because staff state they are going home. Staff S1-S6 stated residents are treated with dignity and respect. LPA Monter interviewed residents R1-R9. R1 stated he/she has never been left alone, unattended in the dinning room for an extending period. Residents R3-R8 stated they have not seen residents left unattended in the dining room for an extending period. Residents R1, R3-R8 stated they are treated with dignity and respect. Resident R2 and R9 were unavailable to be interviewed. The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. This report was reviewed with Executive Director Alex Baisu and Valentine Mathangani, Health & Wellness Director III and a copy of the report was provided. PAGE 3 OF 3.the state’s words, verbatim · CDSS document, Aug 2, 2024 · control 26-AS-20240705113111

Allegation investigated: Staff leaves residents soiled for extended periods of time

Licensing Program Analysts (LPAs) Christine Dolores and Marcella Tarin arrived unannounced to deliver the finding of the above allegations. LPAs met with Executive Director Alex Baisu. On 07/01/2024, the Department received the complaint. On 07/10/2024, the initial complaint investigation was conducted. The following documents were obtained for this investigation to include the resident roster, staff roster, staff schedule, 2 resident's physician's report, service plan, progress notes, face sheet, and medication administrator record (MAR). PAGE 1 OF 2. Substantiated It was alleged that staff (S3) left a resident (R3) soiled for an extended period of time. On 07/10/2024, 7 residents, 6 staff members, and 1 witness were interviewed. Based on staff interview, after a shift change staff (S4) observed R3 was left in double diapers with both diapers filled with R3’s stool. It was stated that the AM shift caregiver left R3 in soiled double diapers since the morning. The review of records show that on 05/28/2024 care staff documented their observation of R3 being left in dirty double diapers with stool from the AM shift. The Department has investigated the above allegation and the preponderance of evidence standard has been met, therefore, the above allegation is SUBSTANTIATED. A deficiency was cited per California Code of Regulations, Title 22. See LIC9099-D. This report was reviewed with Executive Director, Alex Baisu and a copy of the report and appeal rights were provided. PAGE 2 OF 2. Staff handles residents in a rough manner It was alleged that staff (S1) handled resident (R1) in a rough manner by squeezing R1’s arm when transferring. It was alleged that R1 stated they were hurting and S1 would yell stating he/she is not doing anything. On 07/10/2024, 7 residents, 6 staff members, and 1 witness were interviewed. Based on staff interviews, a staff (S2) witnessed S1 squeeze R1’s arm during a transfer. S2 states that he/she did not believe S1’s intention was to hurt R1. S2 states R1 was not hurt and did not observe any bruises on R1 after the incident. 4 out of 6 staff denied the observation of a staff squeezing R1’s arm. 1 out of 6 staff states to have heard of this incident occurred from another staff member. Based on resident interview, R1 did not think S1 squeezed his/her arm when assisting him/her during a transfer. It was stated that staff treats R1 nicely and none of the staff has hurt him/her. 6 out of 7 residents denied staff handling them in a rough manger. 6 out of 7 residents denied the observation of staff handling other residents in a rough manner. 1 out of 7 residents stated that sometimes the new staff are a little rough when handling R2’s care needs. R2 was unable to provide names of the staff and dates of when these incidents occurred. Based on witness interview, W1 denied observing staff handle residents in a rough manner. Staff yells at residents in care It was alleged that staff (S1) yells at resident (R1). It was also alleged that staff (S3) yells at the residents. On 07/10/2024, 7 residents, 6 staff members, and 1 witness were interviewed. PAGE 2 OF 3. Based on resident interviews, R1 denied staff yelling at him/her. It was stated that staff treats R1 nicely and none of the staff has hurt him/her. 7 out of 7 residents denied staff yelling at the residents. 7 out of 7 residents denied the observation of staff yelling at other residents. Based on staff interviews, 6 out of 6 staff members denied the observation of staff yelling at the residents. Staff does not ensure resident’s medications are administered It was alleged that staff (S3) does not ensure R3’s medications are administered and it was alleged that the resident’s medication was found on the resident’s floor. On 07/10/2024, 7 residents, 6 staff members, and 1 witness were interviewed. Based on resident interview, 4 out of 7 residents does not have medication management. 3 out of 7 residents interviewed has medication management. 3 out of 3 residents state the staff administers their medications daily. 3 out of 3 residents denied issues or concerns regarding their medication administration. Based on staff interview, 6 out of 6 staff state the residents are being administered their medications. 6 out of 6 staff denied the observation of seeing loose medication on the floor. On 07/10/2024, LPA Dolores audited R3’s medication with staff. Based on observation, R3’s medications are being administered per doctor’s orders. The Department has investigated the above allegations. Based on interview, record review, and observation the above allegations are unsubstantiated. An unsubstantiated finding indicates that although the allegation may have happened and/or is valid there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Executive Director, Alex Baisu and Valentine Mathangani, Health & Wellness Director III a copy of the report was provided. PAGE 3 OF 3.the state’s words, verbatim · CDSS document, Aug 2, 2024 · control 26-AS-20240701152918

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87625(b)(3) · Plan of correction due date: Aug 3, 2024

(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement is not met as evidenced by: Based on interview, record review and observation the licensee did not ensure resident (R3) was left clean and dry as R3 was found in dirty double diapers which poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 2, 2024

Plan of correction: Licensee states the topic of incontinence care will be provided during all-staff meetings going foward. Licensee will provide the incontinence care training from 07/26/2024 and statement of understanding of the section cited today to LPA Dolores via email by POC due date.

Allegation investigated: Facility staff coerced resident to pay for additional services.

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with the Health and Wellness Director, Valentine Mathangani stated the purpose of today’s visit. On 3/19/2024, the Department received a complaint with the above allegation. On 3/19/2024, the Department conducted an initial investigation at the facility. It was alleged the facility is forcing R1 to pay for medication administration when R1 is able to manage medication. Continuation on LIC 9099-C, Page 1 of 2. Unfounded Page 2 of 2. On 3/20/2024, LPA Rai interviewed 2 staff. S1-S2 stated R1 is not capable to manage his/her own medication, therefore the facility staff will manage the medication and R1 will see the charge on the invoice. S1 and S2 stated R1 does not take the medication prescribed by the physician, sometimes its by choice or R1 is not aware of taking the medication. S1 stated R1 was admitted to the hospital and skilled nursing facility for more than a month and R1 was being provided the medication during the stay. S2 stated the facility staff are working with R1’s primary care physician and physician has agreed with resident needing assistance with medication management. S2 stated R1 has been assessed and R1 has not demonstrated that the resident can management medication. Based on record review of R1’s Physician’s Report dated 8/29/2023 and 3/12/2024, R1 was assessed, and physician reported R1 is not able to administer own prescription and PRN medications. Based on review of R1’s Self Administration of Medication review dated 3/14/2024, R1 is unable to identify the expiration date of each medication, state what each medication is for, state what time medications are to be taken, state the proper dosage for each medication. Based on R1’s Progress Note for 3/15/2024, R1 had an appointment with R1’s primary care physician who order R1 to stay on medication management. Based on the records, R1 is not able to manage medications and facility staff will need to assist R1. On 5/16/2024, LPA Rai interviewed R1. R1 stated he/she recalls the HWD and the primary care physician speaking with him/her regarding the medication management. R1 stated he/she is aware of the facility adding the medication management charges and did not feel like it was coerced, but R1 would like to manage the medications on his/her own. R1 did not recall the assessment questions, but understands why the facility and primary care physician may want the facility staff to manage the medications on his/her behalf. The Department has completed the investigation of the above allegation. Based on interviews conducted and record reviews, the department has found that the above allegation was UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Health and Wellness Director, Valentine Mathangani and a copy of the report was provided.the state’s words, verbatim · CDSS document, May 16, 2024 · control 26-AS-20240319114814

Allegation investigated: Licensee is charging resident for services not provided

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with the Health and Wellness Director, Valentine Mathangani and stated the purpose of today’s visit. On 3/13/2024, the Department received a complaint with the above allegation. On 3/13/2024, the Department conducted an initial investigation at the facility. It was alleged resident (R1) was paying for care services while out of the facility and admitted to the hospital. On 12/12/2023, R1 was taken the hospital due to a health concern. R1 was admitted to a skilled nursing facility after hospital discharge and did not come back to the facility. R1’s belonging are in the room, as well as R1’s spouse currently residing in the room. Continuation on LIC 9099-C, Page 1 of 2. Unfounded Page 2 of 2. On 3/20/2024, LPA Rai interviewed AED, Alex Baisu and 2 staff (S1-S2). AED and S1 confirmed R1 is not in the community during today’s visit and R1 is admitted at the skilled nursing facility. AED, S1 and S2 stated R1’s belongings are present at the facility and is expected to pay the invoice. AED and S1 stated the invoice will state the care services, but after 14 days, the system will reimburse the charges due to resident being out of the facility. S1 stated the facility is not requesting for the resident to pay for care costs since they are not providing the care to R1, but the Admission Agreement states the residents need to pay for the rent while they are away from the facility. On 3/20/2024, LPA Rai interviewed R1’s spouse (R2) who resides in the same room as R1. R2 confirmed R1 has not been in the community since 12/12/2023. R2 stated he/she understands the rent agreement in where R1 will be charged the Basic Service Rate, but does not understand if the facility should charge for the Personal Service Rate. Based on review of R1’s Admission Agreement on page 7 under “C. Absence, section 2. Fees During Absence”, it stated “if you are absent from the Community for any reason, such as, for a hospitalization, vacation, temporary nursing home care or rehabilitation, the Residency agreement will remain effective and you will be charged the full Monthly Service Rate.” The Admission Agreement is signed by R1’s Financial Power of Attorney. Based on review of R1’s Amount History Report dated 3/20/2024, R1 was charged the Personal Service Rate of on 01/01/2024, 02/01/2024, 3/1/2024 and 4/1/2024. However, R1 was credited the "Care Credit - One Time" on 2/15/2024, 3/14/2024, and again on 3/14/2024. As indicated by AED and S1, the billing system did reimburse R1 for the care services after 14 days since R1 was out of the facility. The facility did reimburse R1 in a timely manner in February, and twice in March. The Department has completed the investigation of the above allegation. Based on interviews conducted and record reviews, the department has found that the above allegation was UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Health and Wellness Director, Valentine Mathangani and a copy of the report was provided.the state’s words, verbatim · CDSS document, May 16, 2024 · control 26-AS-20240313160527

Type of visit: Case Management - Incident

On May 3, 2024, Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced case management-Incident visit regarding a SOC341 that was sent to the Department. LPA met with Administrator Momo Duoa and explained the purpose of the visit. On April 30, 2024, the Department received a SOC341 reporting allegations of psychological abuse from staff S1-S4. LPA interviewed resident R1 and ADM. LPA requested staff S1-S4 LIC501 and training documents. LPA also requested a copy of videos as well. LPA requested a copy of R1's physician's report, needs and service plan and emergency contact form. This incident requires further investigation. This report was reviewed with Administrator Momo Duoa and a copy of the report was provided.the state’s words, verbatim · CDSS document, May 3, 2024

Allegation investigated: Staff not meeting residents care needs Resident not administered medication as prescribed

On 4/24/2024, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint inspection. LPA met with Executive Director, Momo Duoa and explained the purpose of the visit. During the visit, LPA conducted a tour of the facility, interior and exterior to ensure there are no potential or immediate health and safety risk at the facility. On 01/05/2021, the Department received a report alleging that staff not meeting residents care needs and resident not administered medication as prescribed. The Department conducted interviews and record reviews. Based on the information available, it was unable to prove whether staff were not meeting residents care needs and resident was not administered medication as prescribed. 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 above allegations are unsubstantiated, at this time. No deficiencies were cited during the visit. Report is reviewed and copy is provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 24, 2024 · control 26-AS-20210105093442

Allegation investigated: Facility staff has not been trained properly Facility is understaffed Facility staff is not following doctor's orders

On 4/2/2024, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint inspection. LPA met with Associate Executive Director Alex Baiasu and explained the purpose of the visit. During the visit, LPA conducted a tour of the facility, interior and exterior to ensure there are no potential or immediate health and safety risk at the facility. On 03/08/2021, the Department received a report alleging that facility staff has not been trained properly; facility is understaffed; and facility staff is not following doctor’s orders. The Department conducted interviews and record reviews. Based on the information available, it was unable to prove whether the facility staff had not been trained properly; the facility was understaffed; and the facility staff was not following doctor’s orders. 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 above allegations are unsubstantiated, at this time. No deficiencies were cited during the visit. Report is reviewed and copy is provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 2, 2024 · control 26-AS-20210308113616

Allegation investigated: Facility did not follow COVID mitigation prevention protocols Staff do not maintain the kitchen in clean and sanitary condition Staff did not ensure faciltiy was free of pests

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with the Associate Executive Director, Alex Baiasu and stated the purpose of today’s visit. On 12/11/2023, the Department received a complaint with the above allegations. On 12/21/2023, the Department conducted an initial investigation at the facility. On 12/21/2024, LPA Rai interviewed 7 staff. Continuation on LIC 9099-C, Page 1 of 4. Unsubstantiated Page 2 of 4. Staff do not follow infection control practices In December 2023, the facility had positive cases of COVID-19 among the residents and facility staff. Per Community Care Licensing Division Provider Information Notices (PIN) 23-13-ASC, the PIN states “As the rick for transmission increases in the community, wearing a mask is an important consideration for Adult and Senior Care (ASC) facilities where higher risk individuals are present…Licensee should follow the strictest requirements.” On 12/21/2023, the Department interviewed 7 staff at the facility. Associate Executive Director (AED) stated the Health and Wellness Director overseeing the COVID-19 procedure at the facility. Health and Wellness Director (HWD) stated the facility has reported cases on the local Public Health Department’s SPOT website and facility has been conducted mass testing of residents and staff. HWD stated they clean and sanitize the facility and staff are required to wear masks during the exposure time frame. 4 Out of the 7 staff stated the staff are required to wear a mask and staff do wear masks in the facility during exposure time frame. 1 Out of the 7 staff stated there have been incidents where more than one staff do not wear a mask in the facility, but the facility management will remind staff when observed not wearing the mask in the facility. On 3/20/2024, LPA Rai interviewed 1 resident (R1). R1 stated he/she did observe staff wearing a mask when the facility required everyone to wear the mask for safety. Staff do not maintain the kitchen in clean and sanitary condition On 12/11/2023, it was alleged the kitchen is not clean and the coffee pots and kitchen machinery is not being cleaned. On 12/21/2023, LPA observed the kitchen area with Associate Executive Director (AED). LPA observed the flooring of the kitchen area free of pests, debris and visible food particles. LPA observed kitchen appliances and coffee pots to be clean and in sanitary conditions. LPA observed coffee pots that were not in use were clean and drying on a rack. Continuation on LIC 9099-C, Page 3 of 4. Page 3 of 4. On 12/21/2023, LPA interviewed the Executive Head Chef (EHC), who stated each staff in the kitchen has their areas they need to clean and there is a schedule of when and where the staff need to clean. EHC stated once the area or kitchen items are cleared, the staff need to initial to state the task has been completed. Based on record review of Cleaning Schedule for Cooks from 12/1/2023-12/20/2023, staff initials all areas of the kitchen were cleaned daily, such as ovens, fryer, grill and work stations. Staff did not ensure facility was free of pests On 12/11/2023, it was alleged that pests were seen in resident rooms and in the facility, such as the attic and kitchen. On 12/21/2023, the Department interviewed 7 staff at the facility. 0 Out of the 7 staff stated there have been pests in the kitchen. 1 Out of the 7 staff stated there have been pests in the attic. 4 Out of the 7 staff stated there have been pests in the resident rooms. 5 out of 7 staff stated there have been incidents of pests in resident rooms, but management does respond in a timely manner, wherein the maintenance team will spray or set the traps. On 12/21/2023, LPA Rai toured the kitchen with Associate Executive Director (AED) and did not observe any signs of pests and the kitchen floor was clear of any visible debris or food particles. AED stated the facility conducts extermination visits on a monthly basis. AED stated when a concern is brought up regarding pests in the facility, they will schedule a visit for exterminators to come out in addition to the monthly visits. Based on review of service Invoices for an exterminator vendor, the facility had extermination services on 11/7/2023 and 12/5/2023 and there was no pest activity found, which included mice and cockroaches. On 12/11/2023, LPA observe at random two resident rooms and did not observe any pests, such as mice or cockroaches. On 3/20/2024, LPA Rai observed at random two resident rooms and did not observe any pests, such as mice or cockroaches. Continuation on LIC 9099-C, Page 4 of 4. Page 2 of 2. On 12/11/2023, it was alleged that a resident with active MRSA was residing at the facility. MRSA is a bacteria which is highly infectious and cause infections in different parts of the body. On 12/21/2024, the Department interviewed Health and Wellness Director (HWD), who stated the facility does not have a resident with a prohibited health condition. LPA reviewed California Code of Regulation 87615 Prohibited Conditions, which included inflection such as Staphylococcus aureus "Staph" and MRSA. HWD stated the facility does not have residents with active MRSA. Staff S1 and S4 stated the residents do not have MRSA. Staff S2 stated there hasn’t been a case of MRSA in the building in the last 2 year. Staff S3 stated he/she does not have knowledge of residents having MRSA. Based on the record review of Incident Reports the facility has sent to the Department, the facility has not reported a case of MRSA in the building in the last 2 years. HWD stated there are residents that are placed in isolation due to being positive for COVID-19 and the facility staff following Infection Control guidelines. The Department has completed the investigation of the above allegations. Based on interviews conducted and observation, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Administrator and a copy of the report was provided. Page 4 of 4. On 3/20/2024, LPA Rai interviewed 1 resident (R1). R1 stated he/she has not observed mice, cockroaches or other pests in his/her room. R1 is not aware if pests were observed in other parts of the facility. LPA Rai observed R1's room and did not observe pests during visit. Based on the interviews conducted with staff, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED. No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Administrator and a copy of the report was provided.the state’s words, verbatim · CDSS document, Mar 20, 2024 · control 26-AS-20231211110846

Allegation investigated: Facility did not monitor resident's declining health condition

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with Associate Executive Director, Alex Baiasu and stated the purpose of today’s visit. On 12/15/2023, the Department received a complaint with the above allegations. On 12/21/2023, the Department conducted an initial investigation at the facility. On 12/23/2024, LPA Rai interviewed 7 staff. Continuation LIC 9099-C, Page 1 of 2. Unfounded Page 2 of 2. On 11/20/2023, R1 complained of shortness of breathe and was placed on oxygen to improve O2 saturation. On 11/21/2023, R1 had an unwitnessed fall where R’s foot got tangled in the footrest of their electric wheelchair. No injured, bruise or skin tears. Paramedics were called via 911 and determined she was uninjured, and resident declined to go to ER. On 11/22/2023, R1 was confused and was taking new antibiotics for UTI where confused can be a symptom of the medication. On 11/23/2023, R1 refused medication, was feeling nauseous and weak and did not have congestion. R1 vomited right before being transported to the hospital. R1 was admitted to the hospital due to testing positive for COVID-19. Based on review of R1’s records, R1 was being monitored for any changes at the facility from 11/01/2023 to 11/23/2023, when R1 was transported to the hospital. Per R1’s Progress Notes, Medication Technician (Med-Tech) and Nursing staff (LVN, LPN, RN) documented R1’s change of condition, medication administration and medication concerns every day. On 11/21/2023, the Department interviewed staff (S1), a caregiver for R1. S1 stated before being admitted the hospital, R1 used oxygen and was not uncommon for resident to complaint about shortness of breath. S1 stated the staff did advise R1 to go to the hospital but R1 would refuse. The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Administrator and a copy of the report was provided.the state’s words, verbatim · CDSS document, Mar 20, 2024 · control 26-AS-20231215162348