Carefield Castro Valley

Type of visit: Required - 1 Year

On 07/09/2026 at 12:00 PM, Licensing Program Analyst (LPA) Ardalan Gharachorloo arrived unannounced to conduct 1- Year Annual Required inspection. LPA met with Executive Director, Parveen Singh and explained the purpose of the visit. LPA toured the facility including but not limited to 4 residents’ units, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 71 degrees F.The hot water temperature in a residents’ shared bathroom was measured at 118.7 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2- day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 08/01/2025. Emergency Disaster Plan was last posted on 07/09/2026. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 04/10/2026. LPA reviewed 5 residents records and 5 staff records, and all were complete. LPA also reviewed a sample of 4 resident’s medications. LPA reviewed the following documents:LIC 500 Personnel Report, LIC 610E Emergency Disaster Plan, and Current Administrator’s Certificate. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 9, 2026

Type of visit: Case Management - Other

On 01/08/2026 at 10:00 AM Licensing Program Analyst (LPA) Ardalan Gharachorloo arrived unannounced to deliver the amended report for the complaint #15-AS-20250718094347. LPA met with Executive Director, Parveen Singh and explained the purpose of the visit. Amended report delivered to Executive Director. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jan 8, 2026

Allegation investigated: Staff mismanaged resident medication

On 7/24/2025 at 12:15PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegation above. LPA met with Assisted Living Director, Kathy Bedolla and explained the purpose of the visit. During the course of investigation, LPA interviewed 5 staff, 2 residents, and complainant. LPA reviewed and obtained emergency information, med list, MAR, and discharge documents. Interview with staff revealed that narcotic medications are kept locked in the med carts and counted daily. Staff stated med techs have not given the wrong dosage of medications to residents. R2's med list indicated R2 was not taking narcotic medications and R2's MAR revealed that medications were administered to R2 as prescribed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted. A copy of this report provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 24, 2025 · control 15-AS-20250222203747

Allegation investigated: Staff are not meeting residents dietary needs Staff do not seek timely medical attention for residents Licensee does not ensure enough staff to meet residents needs Staff are not dispensing medication as prescribed

On 07/21/2025 at 10:20 AM, Licensing Program Analyst (LPA) Ardalan Gharachorloo arrived unannounced to to deliver findings in regard to the allegations listed above. LPA met with Parveen Singh, Executive Director and explained the purpose of the visit. During the course of the investigation, LPA interviewed five staff members (S1–S5), one witness (W1), and two residents (R1 and R2). LPA also conducted a physical tour of R1 and R2’s shared room. Documents reviewed included the Needs and Services Plans for R1 and R2, Medication Administration Records (MARs), incident reports, physician’s orders, staff training logs, care progress notes, communication logs, the 04/25/2025 staff schedule, and the resident roster. Allegation: Staff are not meeting residents' dietary needs - Unsubstantiated ***CONTINUE ON 9099C*** Unsubstantiated ***CONTINUE FROM 9099*** W1 stated that R1 was not being reminded to eat and was possibly experiencing health decline as a result, including needing a blood transfusion. S1 explained that dietary needs are determined through physician assessments and then communicated to the kitchen staff. The Assisted Living Director works closely with the culinary team to ensure preferences and restrictions are followed. S3 and S4 stated that caregivers and servers monitor who attends meals and report non-attendance or poor appetite to the med tech. S3 said, “We always notice if someone hasn’t eaten. We either check on them or bring a meal to their room.” S4 recalled R1 having occasional fluctuations in appetite but said, “She tells us when she doesn’t like something. She’s very clear.” R1 stated she typically eats in the dining area but sometimes feels tired or forgets, and on those days, someone usually reminds her or brings food to her room. She added, “If I want something, I ask. They usually help.” R2 stated that R1 is socially active and frequently seen in the dining room. Review of meal-related documentation did not show consistent patterns of meal refusal or weight loss. Care notes indicated regular dietary monitoring and no recent physician concerns about nutritional status. Allegation: Staff do not seek timely medical attention for residents - Unsubstantiated W1 stated that R1 had to receive a blood transfusion due to poor medical follow-up and that there was little coordination with her physician. S1 acknowledged that contacting outside providers, particularly Kaiser, can be challenging due to call wait times and follow-up delays. However, S1 and S2 stated that when a family member or resident informs them of a health issue, staff follow protocol by alerting the med tech and care coordinator, and contacting the provider. S5 added, “We’ve had to call Kaiser multiple times to get things moving. It’s not us ignoring anything—it’s just delays from their side.” ***CONTINUE ON 9099C*** ***CONTINUE FROM 9099C*** R1 confirmed that she has experienced delays getting doctor appointments but said staff helped her make calls or forwarded messages. She stated, “They try to help, but Kaiser is slow. I get frustrated, but I don’t blame them.” R2 did not report any issues with medical attention but stated that she manages most of her own appointments. Review of communication logs and incident reports showed attempts by staff to follow up on R1’s medical needs, including calls and coordination of transportation. Allegation : Licensee does not ensure enough staff to meet residents’ needs - Unsubstantiated W1 reported that R1 calls late at night asking for help and expressed concern that the facility may be understaffed or unresponsive during the day. S1 stated that the facility maintains a staffing ratio of approximately 1 staff per 10 residents in Assisted Living, and there are typically 5 to 6 staff members per shift. Staff schedule for 04/25/2025 confirmed this ratio. S2 explained, “We have coverage across all shifts. If someone calls out, we have floaters or back-ups.” S4 and S5 both stated that they check in with residents throughout the day and respond to call buttons promptly. S4 noted, “If someone says they’re not getting attention, it’s probably because they didn’t let us know. We try to anticipate needs, but we can’t guess everything.” S5 added, “We always have someone walking the floor.”R1 confirmed that staff generally respond when she presses her call pendant, though she mentioned she sometimes calls her family late at night because she “just feels anxious.” She said, “It’s not that they’re not helping me—it’s more that I don’t want to bother them sometimes.” R2 reported no concerns about staffing levels or response times. Review of staffing records did not indicate staffing shortages. ***CONTINUE ON 9099C*** ***CONTINUE FROM 9099C*** Allegation : Staff are not dispensing medication as prescribed - Unsubstantiated W1 stated that R1 has a prescription for anxiety that was never filled and expressed concern about medications that are supposed to be taken every three hours. S1 stated that all medications are managed using MARs and administered by trained med techs. S3 explained that medication times are scheduled based on physician orders and any special instructions are clearly marked. S3 stated, “We’re very strict with the med passes, especially for time-sensitive meds. We double-check the MAR each shift.” S5 added that when a prescription is delayed due to pharmacy or provider issues, it is documented and the family is informed. According to S2, the anxiety medication W1 referred to had not been delivered by the pharmacy and was under follow-up .R1 acknowledged that one of her medications hadn’t arrived yet but said she was aware of the reason and had spoken to staff about it. “They told me they’re waiting on it from the doctor. I’ve been okay,” she said. R2 reported no issues with medication timing or availability. Review of MARs confirmed consistent medication administration. The anxiety prescription was noted as “pending delivery,” with follow-up calls documented. According to MAR, there were no missed doses of other routine medications. This agency has investigated allegations above. We have found that the above allegations were unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview conducted, a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 21, 2025 · control 15-AS-20250422105348

Type of visit: Required - 1 Year

On 07/03/2025 at 9:55 AM, Licensing Program Analyst (LPA) Ardalan Gharachorloo arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director, Parveen Singh and explained the purpose of the visit. LPA toured the facility including but not limited to 6 residents’ apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 71 degrees F. The hot water temperature in a residents bathroom was measured at 106 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 06/29/2025. Emergency Disaster Plan was last posted on 05/16/2025. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 05/22/2025. LPA reviewed 5 residents records and 5 staff records, and all were complete. LPA also reviewed a sample of 6 resident’s medications. The following documents were reviewed during the visit: LIC 500 Personnel Report LIC 610E Emergency Disaster Plan, Liability Insurance ,and Current Administrator’s Certificate. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 3, 2025

Allegation investigated: Lack of supervision resulted in resident sustaining in multiple fractures from unwitnessed falls.

On 6/04/2025 at 1 p.m. Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced visit to deliver the findings for the above complaint allegations. LPA met with Executive Director Parveen Singh, explained the purpose of the visit. Allegation: Lack of supervision resulted in resident sustaining in multiple fractures from unwitnessed falls- Substantiated On 09/07/2022, The department reviewed the record of R1, including medical record, care note, facility’s protocol, and staff interview. Report continued on LIC 9099c... Substantiated Allegation: Facility failed to meet the resident's needs. Unsubstantiated It was alleged facility failed to meet the resident’s needs, however, the department conducted staff interviews, reviewed R1’s assessments, and the care plan shows R1 does not need a one-on-one for all three R1 assessments, dated 10/2/2021, 2/17/2022, and 8/25/2022. However, R1 was to have 4 to 8 status checks per shift by a caregiver. After this incident, S3, S2, and S1 all decided to "have more eyes" on R1. "Having more eyes" means checking on R1 more. S6 told caregivers to watch R1 and R1's behavior. After R1 falls and R1 comes back from the hospital, the staff would monitor R1 more frequently and follow R1's discharge instructions During safety checks on R1, S9 would "pop in" the R1 room. Check to see if R1 was breathing or sitting. Checks were quick and lasted about two minutes. For the PM shift, S9 checks on residents about three to four times. S9 would always check on R1 before S9 left. Checks are not being documented. On 3/22/23 S6, S7, and S9 stated R1 refused to get change and bathing most time, and when R1 does want assistance, it depend on R1 mood. However, most time R1 doesn’t want to get assistant with ADL because to R1, R1 think R1 can still manage by R1 that R1 is still independent. Conducted interviews with S1, S2, S3, S4, S6, S7, S8, S9, S10, and HHN stated R1 is being checked 4 to 8 times, and always with a staff member. Report continues on KIC 9099c... Allegation: Lack of care resulted in resident sustaining multiple urinary tract infections. Unsubstantiated On 6/18/2021, R1 was admitted to the assisted living side of Carefield Castro Valley. R1 had been in and out of the hospital during R1's time at the facility. R1 was transported to Kaiser in San Leandro in January 2022, due to urinary tract infection (UTI), followed by COVID-19, and low platelets. Records reviews R1’s contacted UTI on 1/17/2022, 7/13/2022, and 8/23/22. However, before the three different events that R1 contracted, UTI S1 had requested R1 to get a check-up. S1, S6, S7, S8, and S9 encouraged R1 to drink more water, but R1 asked to be left alone. Staff stated they cannot force anyone to do anything they don’t want; they can only encourage. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report are provided. Based on interviews of staff at the Carefield Castro Valley facility, R1 was admitted on 6/18/2021 and was transferred from the Assisted Living side of the facility to the Memory Care side on 2/18/2022 because of R1’s dementia diagnosis and a recommendation from Kaiser Memory Care Clinic for R1 to be in Care. Memory Care staff and documents show a history of seven falls from 5/4/2022 to 8/17/2022. Staff statements show R1 was considered a fall risk and that R1’s condition had changed both mentally and physically. Staff statements confirmed that R1 believed R1 could stand up and walk without assistance, however, R1 would fall and sustain multiple unwitnessed falls while being in R1’s room. Staff were aware to frequently check on R1, however, R1 fell multiple times. S1 stated S1 would keep R1 with S1 while working because S1 wanted to keep a closer eye on R1, however, the evidence does not show S1 gave any instructions to direct care staff to provide care and supervision to R1 to prevent R1 from falling in R1 room. Although facility staff were aware of R1's multiple falls, they failed to take adequate measures to ensure R1’s safety, resulting in multiple falls and/or being found on the floor in R1's room. R1 was sent by the facility to Kaiser on 5/4/2022, 7/11/2022, 7/13/2022 (twice), 8/17/2022, and 8/23/2022. R1 was diagnosed with fractured ribs on 7/13/2022 and a fracture to the T9-T10 vertebrae on 8/17/2022. Based on evidence obtained during the course of this investigation, the Department has determined that lack of supervision resulted in resident sustaining multiple fractures from unwitnessed falls. This is a factual determination based on all the facts and circumstances of the case. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. Exit interview conducted. Appeal Rights and a copy of this report are provided.the state’s words, verbatim · CDSS document, Jun 4, 2025 · control 15-AS-20220824162155

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Jun 13, 2025

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced: Based on evidence obtained during the course of this investigation, the Department has determined that lack of supervision resulted in resident sustaining multiple fractures from unwitnessed falls. This is a factual determination based on all the facts and circumstances of the case.the state’s words, verbatim · CDSS document, Jun 4, 2025

Plan of correction: By POC date, Excutive Director agrees to review regulation and submit self-certification letter stating the understand of regulation.

Type of visit: Required - 1 Year

On 07/23/2024 at 10:21 AM, Licensing Program Analyst (LPA) Ardalan Gharachorloo arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Katherine Maningding and explained the purpose of the visit. LPA toured the facility including but not limited to 5 residents’ apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 72 degrees F. The hot water temperature in a residents’ shared and private bathrooms were measured at 111.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 06/30/2024. Emergency Disaster Plan was last posted on 07/18/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 06/11/2024. LPA reviewed 5 residents records and 6 staff records, and all were complete. At 11:42 AM, LPA also reviewed a sample of resident’s medications and medications log in the medications room. At 12:25 PM, LPA reviewed the following documents: LIC 308 Designation of Administrative Responsibility, LIC 500 Personnel Report, LIC 610E Emergency Disaster Plan, Liability Insurance, and Current Administrator’s Certificate. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 23, 2024

Allegation investigated: Staff do not ensure facility is maintained clean Staff do not ensure facility is maintained odorless

On 7/1/24 Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct a complaint investigation for the above allegation starting at 12:40pm. LPA met with Parveen Singh Senior Executive Director and explained the purpose of the visit. Allegation: Staff do not ensure facility is maintained clean: Unsubstantiated During visit LPA interviewed Senior Executive Director, and three other care staff. LPA took a tour of the facility including but not limited to dining area, assisted living and memory care unit. LPA tour R1, R2, R3, R4, R5, and R6 room in memory care unit. LPA observed facility is clean and clear of obstruction. LPA observed that there is no furniture that is in disrepair. Report continued on LIC 9099C... Unsubstantiated Allegation: Staff do not ensure facility is maintained odorless: Unsubstantiated LPA observed in memory care unit there is no odor smell. LPA observed in R1, R2, R3, R4, R5, and R6 room are kept clean and odor free. LPA interview S1, S2, and S3 stated that there has not been any odor that they notice in the building or in any resident’s room. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided via email.the state’s words, verbatim · CDSS document, Jul 1, 2024 · control 15-AS-20240625113906