Carlton Plaza of San Jose

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced case management visit regarding an incident report, regarding a death report for a resident referred to as R1. LPA met with Administrator Shantela Yadao and explained the purpose of the visit. On August 21, 2026, the Department received an incident report stating on resident R1 had passed away. The Department contacted the facility administrator and requested a copy of R1's Physicians Report, Care plan and progress notes. On August 26, 2026, Licensing Program Analyst Manuel Monter interviewed ADM Shantela Yadao and 2 staff. Facility will collaborate with the family/responsible party and get a copy resident R1's death certificate once it becomes available. At this time, this case in under review and Department will conduct a follow visit , if warranted. No deficiencies cited during today's visit. This report was reviewed with Administrator Shantela Yadao and a copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 26, 2026

Allegation investigated: Staff did not follow infection control protocols.

Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegations. LPA met with Administrator Shantela Yadao. On July 31, 2026, the Department received a complaint alleging Staff did not follow infection control protocols. On August 04, 2026, Licensing Program Analyst Manuel Monter interviewed staff S1-S12. 12 Out of 12 staff (S1-S12) stated staff are following infection control protocols by: isolating covid positive residents, using PPE when interacting with covid positive residents, cleaning high traffic/common areas, and having hand sanitizer readily available in the dinning area and on each floor of the facility. S12 stated they placed PPE and a cart outside the covid positive apartments to don and doff their PPE after entering a covid positive resident bedroom. Page 1 Out of 3. Unfounded On August 4, 2026, Licensing Program Analyst Manuel Monter interviewed Administrator (ADM) Shatela Yadao. ADM stated for every resident that is covid positive, they have a station outside that residents bedroom with PPE for staff to use when entering said bedroom. ADM stated the facility’s nurses do their checks daily and testing as well. ADM stated they are testing the covid positive residents every 3 days. ADM stated they are quarantining the residents who are covid positive. ADM stated the facility is delivering meals to the covid positive residents. ADM stated they have been cleaning/sanitizing high touch / traffic areas. ADM stated hand sanitizer is available for residents as well. ADM stated the facility recommends that residents who test positive for covid limit visitors during their quarantine period. ADM stated that if visitors must enter the apartment of a covid positive resident, they are instructed to use personal protective equipment (PPE). ADM stated that visitors of residents who are not covid positive are asked to reschedule their visit if they are feeling unwell. ADM reported that residents may otherwise visit with their guests as they choose. ADM stated that masks and hand sanitizer are available for anyone who requests them. ADM stated that an email was sent to families notifying them that there are active COVID 19 cases in the facility. ADM she contacted the Department of Public Health for guidance. ADM stated the facility is following their infection control protocol. On August 4, 2026, Licensing Program Analyst Manuel Monter interviewed Residents R1-R3. 3 Out of 3 residents (R1-R3) stated they have seen staff wearing masks and gloves. 3 Out of 3 residents (R1-R3) stated they have observed the facility providing hand sanitizer in each floor. 3 Out of 3 residents (R1-R3) stated they have observed the facility staff cleaning the high traffic / high touch areas. 3 Out of 3 residents (R1-R3) stated they do not have any concern regarding the facility’s response to covid. On August 19, 2026, Licensing Program Analyst Manuel Monter interviewed residents R4-R8. 5 Out of 5 residents (R4-R8) stated they have observed facility staff cleaning high traffic areas, wearing masks and wearing gloves as well. 5 Out of 5 residents (R4-R8) stated they have also seen the facility place stations of PPE outside the rooms of residents who are covid positive. 5 Out of 5 residents (R4-R8) stated they have seen the facility providing hand sanitizer in the common areas of the facility including the dinning area. Page 2 Out of 3. On August 21, 2026, Licensing Program Analyst Manuel Monter interviewed staff S13-S16. 4 Out of 4 staff (S13-S16) stated staff are following infection control protocols which includes: isolating covid positive residents, using PPE when interacting with covid positive residents, cleaning high traffic/common areas, and having hand sanitizer readily available in the dinning area and on each floor of the facility. On August 21, 2026, LPA interviewed ADM Shantela Yadao. ADM stated as of today, August 21, 2026, the facility does not have any residents who are Covid 19 Positive / showing symptoms. On August 4, 2026, the Department received 2 incident report from the facility noting there was 5 residents who tested positive for Covid 19. On August 7, 2026, the Department received an incident report noting there was an additional case of Covid 19 at the facility. The Department reviewed the facility’s training records. On July 30 and 31, 2026, the facility conducted COVID/infection control and PPE training for staff. The Department reviewed the facility's Infection Control Plan, dated July 8, 2026. The plan states the following procedures will be followed when there are one or more residents are diagnosed with a contagious disease. The procedures include the following but not limited to actions: Cleaning to maintain a safe and sanitary environment to prevent, contain and mitigate the transmission. Staff providing direct care to residents who has a contagious disease shall wear PPE to prevent exposure to infectious agents. The facility will consult with local health Department. The facility will provide additional training to staff regarding the specific contagious disease and infection control measures. Residents who are positive for the infectious disease will be quarantined. 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 3 Out of 3. End of Report.the state’s words, verbatim · CDSS document, Aug 21, 2026 · control 26-AS-20260731113322

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator Shantela Yadao. LPA explained the purpose of the visit. LPA toured the facility inside out with ADM which included the 1-3 floors of the facility. The our included the Living room common areas, kitchen, dining room, restrooms and residents bedrooms which included, but not limited to bedrooms: 112,131,128, 126, 125, 120, 116, 226, 210, 231, 221, 213, 235, 215, 329, 334, 337, 341, 333, 341, 337, and room 316. There was no obstruction to block the walkways. The staff area of the facility was also inspected. The front yard and backyard were inspected. Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 75 degrees F, and hot water temperature was measured at 118 degrees F in resident bathrooms. Fire extinguishers were serviced in June 17, 2026. The facility was equipped with smoke and carbon monoxide detectors. Sprinkler system was last inspected on June 17, 2026. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on July 24, 2026. LPA reviewed facility records for 5 staff and 5 residents. LPA reviewed 5 resident medications and centrally stored medication records. No deficiencies cited during today's visit. This report was reviewed with Administrator Shantela Yadao and a copy of the signed report was provided.the state’s words, verbatim · CDSS document, Aug 4, 2026

Allegation investigated: Staff does not ensure resident can make and receive confidential calls Staff does not ensure resident has a signal to call for help Staff retains resident who wants to relocate Staff does not allow resident to choose their own doctor

Licensing Program Analyst (LPA) Maria (Mita) Partoza, conducted an unannounced visit to deliver the findings of the complaint received by the Department. LPA met with Executive Director/Administrator (ED/ADM) Shantela Yadao. On 05/13/2026, the Department received a complaint with the above allegations. On 05/15/26, LPA conducted interviews with resident and staff and inspected resident rooms and interviewed FM2. LPA gathered documents pertaining to the above allegations. page 1 of 4 Unfounded Facility staff do not ensure resident can make and receive confidential calls. The reporting party (RP) stated Resident 1 (R1) could not receive telephone calls from family members and was upset because staff did not allow R1 to receive calls. On 05/15/2026, LPA interviewed R1 who stated he/she uses a personal cellular phone to send text messages and communicates by text messages because of difficulty hearing voice calls. LPA interviewed resident 2 (R2), who stated R2 uses a personal cellular phone to make and receive calls and stated no one listens to R2’s telephone conversations. LPA interviewed staff 1 and 2 (S1 and S2), who stated residents use personal cellular phones to make and receive calls and staff do not participate in residents’ personal communications. Based on interviews and observations, LPA observed R1 using a personal cellular phone and receiving text messages. LPA observed R1’s room did not have a landline telephone. Facility staff do not ensure resident has a signal to call for help. The reporting party (RP) stated staff removed R1’s signal device and R1 could no longer signal for help. On 05/15/2026, LPA inspected six (6) resident rooms and observed the facility was equipped with emergency pull cord systems mounted on the wall of the bathroom, living area, and next to the bed, residents had call pendants, voice-activated communication devices in the assisted living section, and a monitoring system designed to detect falls in the memory care section. While conducting the interview with R1, LPA asked permission from R1 to test his/her call pendant and R1 consented. LPA observed staff responded to the call within five minutes. R1 stated he/she uses the call pendant and emergency pull cord when assistance is needed. LPA interviewed R2, who stated R2 has access to a call pendant, emergency pull cords, and a voice-activated communication device. LPA asked permission from R2 to test the call pendant and R2 consented. LPA observed staff responded within five minutes. S1, S2, and staff 3 (S3) stated residents have access to emergency call pendants, pull cords, and voice-activated communication devices to contact staff. S1, S2, and S3 demonstrated how residents use the voice-activated communication device to contact the front desk. page 2 of 4 Based on observations, LPA observed resident apartments were equipped with emergency pull cords strategically placed in the resident’s room, residents had emergency pendants, and voice-activated communication devices. LPA observed memory care resident apartments were equipped with a fall detection system. Facility staff retain resident who want to relocate. The reporting party (RP) stated R1 wanted to relocate from the facility and staff did not listen to R1 when R1 expressed a desire to leave. On 05/15/2026, LPA interviewed R1, who stated he/she wanted to move out of the facility and live with family member 1 (FM1). R1 stated he/she discussed moving out of the facility with family member 2 (FM2) and expressed that he/she had decided to move in with FM1. R1 stated FM2 did not agree. LPA interviewed S1, S2, and S3, who stated residents may relocate from the facility at any time; however, residents are requested to provide 30-day written notice. S2 and S3 stated R1's responsible party was FM2, FM2 would notify the facility by providing the required 30-day written notice. S1, S2, and S3 stated staff do not prevent residents from relocating from the facility. S3 stated that FM2 was aware of R1’s desire to relocate and live with FM1. On 05/18/2026, LPA interviewed FM2, who stated he/she and FM1 disagreed regarding R1's relocation from the facility. On 05/19/2026, LPA received email correspondence from FM2, who stated family members discussed R1's request to relocate from the facility. FM2 stated they were not going to prevent R1 from leaving the facility with FM1. FM2 further stated R1 left the facility with FM1. On 05/21/2026, LPA received and reviewed email correspondence from S3, which included an email from FM2 dated 05/17/2026 notifying the facility that FM1 would be taking R1 to an appointment and that the email should serve as R1's 30-day written notice if R1 did not return to the facility. S3 stated R1 left the facility with FM1 and did not return to the facility. page 3 of 4 LPA reviewed R1's admission agreement, which states: The resident may terminate the agreement at any time, with or without cause, by providing the Executive Director or designee with 30 days' written notice. Facility staff do not allow resident to choose their own doctor. The reporting party (RP) stated facility staff required R1 to use a physician associated with the facility. On 05/15/2026, LPA interviewed R1, who stated he/she has a personal physician and no staff at the facility told R1 to see a different physician associated with the facility. LPA interviewed R2, who stated he/she can choose a physician and had not been told which physician to see. LPA interviewed S1 and S2, who stated residents may use physicians of their choice and may request to change physicians if they choose. Based on interviews conducted, observations made, testing performed, and records reviewed, LPA observed R1 had access to confidential communications and emergency call systems, reviewed records documenting R1 relocated from the facility following notice provided to the facility, and obtained information from interviews that residents may choose their own physicians. This agency has investigated the complaint with the following allegations that facility staff do not ensure resident can make and receive confidential calls; facility staff do not ensure resident has a signal to call for help; facility staff retain resident who wants to relocate; and facility staff do not allow resident to choose their own doctor. We have found that the complaint was unfounded, meaning that the allegations were false, could not have happened, and/or are without a reasonable basis. No deficiencies were cited based on the California Code of Regulations (CCR) Title 22. An exit interview was conducted and copy of the report was provided to ED/ADM Shantela Yadao Page 4 of 4 end of reportthe state’s words, verbatim · CDSS document, Jul 7, 2026 · control 26-AS-20260513081241

Allegation investigated: Facility overcharged resident. Facility staff did not safeguard resident's personal belongings.

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with Administrator, Shantela Yadao and stated the purpose of today’s visit. On 02/11/2026, the Department received a complaint with the above allegations. On 02/18/2026, the Department conducted an initial investigation at the facility. Continuation on LIC 9099-C, Page 1 of 3. Unfounded Page 2 of 3. Facility overcharged resident. It was alleged that the facility is charging resident $1,400 for the month of December, when resident passed away on 12/2/2025 and family removed resident’s items from the room on 12/04/2025. On 02/18/2026, the Department conducted an interview with Executive Assistant (EA) Yoliana Sanchez-Cruz. EA stated resident passed away in December 2025 and resident’s family removed resident’s items from the room on 12/04/2025. Based on review of R1’s Admission Agreement page 11 out of 18 signed by resident R1 on 07/17/2025, “Your estate (or person or entity responsible for payment of fees under the Residence and Service Agreement) will continue to be responsible for all outstanding fees due at the time of your death and for fees accruing until your personal property is removed from your Apartment.” Based on Invoice dated 12/2025, resident was charged for rent and care from 12/1/2025 – 12/31/2025 for $6,680 and Apartment Room Service for the amount $540. For the dates of 12/1-12/4/2025, when resident R1 was charged for the rent and care until personal property was removed from the Apartment, the amount due to the facility was $1401.93. Based on facility’s records of checks received from resident R1, the last check was processed on 12/5/2025 for the amount due in November 2025 and facility staff did not receive check from R1 for the dates 12/1-12/4/2025, which is the amount due of $1401.93. Based on review of resident's charges, Executive Director did decide for facility to not invoice the resident's family the amount of $1401.93 and the resident's family does not owe any amount to the facility. Facility staff did not safeguard resident’s personal belongings. It was alleged that the facility allowed resident’s family member FM2 to enter resident’s room and take resident’s belongings. On 02/18/2025, the Department conducted an interview with Executive Assistant (EA) Yoliana Sanchez-Cruz. EA stated Executive Director had sent an email on 12/03/2025, 1 day after resident passed away that no one was allowed to enter R1’s room. EA stated the only person that visited the resident and/or resident’s room from 12/1/2025-12/4/2025 was resident’s family FM1 who removed resident’s personal property. Page 3 of 3. Based on review of R1’s Admission Agreement page 11 out of 18 signed by resident R1 on 07/17/2025, R1 designated FM2 to remove personal property from the apartment upon death. During today's visit, LPA Rai interviewed 5 residents (R1-R5). 4 Out of 5 residents (R2-R5) refused to speak with LPA Rai. R1 stated she/he has not heard about R1's personal belongings being missing or misplaced at the facility. R1 stated their personal belongings have not been missing or misplaced at the facility. R1 stated she/he has not heard about other resident's personal belongs being missing or misplaced at the facility. During today's visit, LPA Rai interviewed 5 staff (S1-S5). 5 Out of 5 staff stated it is the process for the facility management to lock the resident's room when the resident is in the process of moving out and only resident's authorized representative is able to enter the room and give authorization to the facility staff and management to enter resident's room. 5 Out of 5 staff stated they are not aware of R1's personal belongings being missing or misplaced in the resident's room. They stated they have not seen or heard, in general, regarding resident's personal belongings being missing or misplaced in the facility. They stated they have not seen or heard, in general, staff stealing or misplacing resident's personal belongings in the facility. During the investigation, LPA Rai reached out to FM2 to conducted an interview but FM2 was not available. 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, Shantela Yadao and a copy of the report was provided.the state’s words, verbatim · CDSS document, May 20, 2026 · control 26-AS-20260211082354

Allegation investigated: Facility overcharged resident. Facility staff did not safeguard resident's personal belongings.

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with Administrator, Shantela Yadao and stated the purpose of today’s visit. On 02/11/2026, the Department received a complaint with the above allegations. On 02/18/2026, the Department conducted an initial investigation at the facility. Continuation on LIC 9099-C, Page 1 of 3. Unfounded Page 2 of 3. Facility overcharged resident. It was alleged that the facility is charging resident $1,400 for the month of December, when resident passed away on 12/2/2025 and family removed resident’s items from the room on 12/04/2025. On 02/18/2026, the Department conducted an interview with Executive Assistant (EA) Yoliana Sanchez-Cruz. EA stated resident passed away in December 2025 and resident’s family removed resident’s items from the room on 12/04/2025. Based on review of R1’s Admission Agreement page 11 out of 18 signed by resident R1 on 07/17/2025, “Your estate (or person or entity responsible for payment of fees under the Residence and Service Agreement) will continue to be responsible for all outstanding fees due at the time of your death and for fees accruing until your personal property is removed from your Apartment.” Based on Invoice dated 12/2025, resident was charged for rent and care from 12/1/2025 – 12/31/2025 for $6,680 and Apartment Room Service for the amount $540. For the dates of 12/1-12/4/2025, when resident R1 was charged for the rent and care until personal property was removed from the Apartment, the amount due to the facility was $1401.93. Based on facility’s records of checks received from resident R1, the last check was processed on 12/5/2025 for the amount due in November 2025 and facility staff did not receive check from R1 for the dates 12/1-12/4/2025, which is the amount due of $1401.93. Based on review of resident's charges, Executive Director did decide for facility to not invoice the resident's family the amount of $1401.93 and the resident's family does not owe any amount to the facility. Facility staff did not safeguard resident’s personal belongings. It was alleged that the facility allowed resident’s family member FM2 to enter resident’s room and take resident’s belongings. On 02/18/2025, the Department conducted an interview with Executive Assistant (EA) Yoliana Sanchez-Cruz. EA stated Executive Director had sent an email on 12/03/2025, 1 day after resident passed away that no one was allowed to enter R1’s room. EA stated the only person that visited the resident and/or resident’s room from 12/1/2025-12/4/2025 was resident’s family FM1 who removed resident’s personal property. Page 3 of 3. Based on review of R1’s Admission Agreement page 11 out of 18 signed by resident R1 on 07/17/2025, R1 designated FM2 to remove personal property from the apartment upon death. During today's visit, LPA Rai interviewed 5 residents (R1-R5). 4 Out of 5 residents (R2-R5) refused to speak with LPA Rai. R1 stated she/he has not heard about R1's personal belongings being missing or misplaced at the facility. R1 stated their personal belongings have not been missing or misplaced at the facility. R1 stated she/he has not heard about other resident's personal belongs being missing or misplaced at the facility. During today's visit, LPA Rai interviewed 5 staff (S1-S5). 5 Out of 5 staff stated it is the process for the facility management to lock the resident's room when the resident is in the process of moving out and only resident's authorized representative is able to enter the room and give authorization to the facility staff and management to enter resident's room. 5 Out of 5 staff stated they are not aware of R1's personal belongings being missing or misplaced in the resident's room. They stated they have not seen or heard, in general, regarding resident's personal belongings being missing or misplaced in the facility. They stated they have not seen or heard, in general, staff stealing or misplacing resident's personal belongings in the facility. During the investigation, LPA Rai reached out to FM2 to conducted an interview but FM2 was not available. 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, Shantela Yadao and a copy of the report was provided.the state’s words, verbatim · CDSS document, May 20, 2026 · control 26-AS-20260211082354

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Case Management - Other visit to deliver an amended report to the facility. LPA met with Administrator, Shantela Yadao and stated the purpose of the visit. The Department received additional information and the complaint investigation from 02/11/2026 was opened and conducted further investigation. During visit, LPA Rai provided a copy of the original and amended report from 05/07/2026 visit was provided for Administrator, Shantela Yadao to review and sign the amended report. This report was reviewed with Administrator, Shantela Yadao and a copy of the report was provided.the state’s words, verbatim · CDSS document, May 20, 2026

Allegation investigated: Facility did not provide resident with a refund Staff are not communicating with responsible party regarding resident's care

Licensing Program Analyst (LPA) Marcela Yanez conducted an unannounced initial complaint investigation visit and met with Shantela Yadao, Administrator. LPA announced the purpose of the visit. On 01/23/26 the department received a complaint with the above allegations. During visit LPA obtained pertinent documents for R1 and interviewed staff and Administrator. During the investigation LPA reviewed Deposit Receipt effective date 10/31/25 signed by Resident Responsible party on 10/29/25. Admissions agreement and email communication between POA and staff. Resident (R1) moved into the facility on 10/31/25 after being assessed by Sales Manager and virtual assessment by nurse at hospital. Sales Manager stated resident did not exhibit behavior at that time of assessment. Unfounded Page 2 of 2 The Deposit Receipt dated and signed by POA on 10/29/25 states that the R1 Community Fee is fully refundable until the Personal Care Interview is completed. After the assessment has been completed $500 dollars of the fee is non refundable. Any balance would be refunded on a pro-rated basis, 1st month is 80% and 2nd month is 60% and 3rd month 40% and after 3rd month is no refund. 4 out of 4 staff stated that R1 exhibited behavior shortly after moving in and POA was notified that R1 might need 1 on 1 care. 4 out of 4 staff stated the POA was informed of change in condition and R1s emergency contact was also notified. S2 stated he/she would call POA when resident had behavior and stated POAs voicemail was not set up and they would call R1s emergency contact who lived nearby. The Residents progress notes stated emergency contact was notified regarding R1s needing refill of medication and when R1 was having behavior. Based on interview and record review the facility refunded the amount of $2500.00 dollars for community fee of 60% of $5000.00 which is a total of $3000.00 minus the $500 non refundable fee that was stated on Deposit Receipt signed by POA. The check was issued on 01/20/26 and was delivered on 01/21/26 and another refund check for $258.00 for 1 day of rental fee when resident moved out on 12/30/25 was sent on 01/13/26. The Department has investigated the above allegations. Based on interviews, and observation the above allegations are unfounded meaning the allegations is false, could not have happened, and/or is without a reasonable basis. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Shantela Yadao and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 28, 2026 · control 26-AS-20260123145949

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced case management visit-other to follow up on the facility's proposed memory care unit expansion. LPA met with Director of Resident Services (RSD) Maricel Ong. LPA explained the purpose of the visit. On January 14, 2026, the Department received notification from regarding their proposed memory care unit expansion. LPA toured the memory care unit and the proposed expansion with RSD. LPA interviewed RSD regarding the proposed change in the memory care unit. No deficiencies cited during today's visit. This report was reviewed with Director of Resident Services Maricel Ong and a copy of the signed report was provided.the state’s words, verbatim · CDSS document, Jan 23, 2026

Allegation investigated: Staff did not address the resident's change in condition. Staff are not meeting resident's medical needs. Staff are not meeting resident's dietary needs.

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Administrator (ADM) Shantela Yadao. On 10/20/2025, the department received a complaint with the above allegations. On 10/29/2025, LPA Marrufo conducted an initial complaint investigation visit. Allegation - Staff did not address the resident's change in condition. - UNFOUNDED R1’s Physician’s Report has an examination date of 06/23/2025. R1’s Physician’s Report states R1 had a diagnosis of “Acute Left basal ganglia stroke.” R1’s Service Plan is dated 06/26/2025. It states R1’s Move-in Date is 06/23/2025. R1’s Service Plan identifies R1’s diagnosis as “Basal Ganglia Stroke.” R1’s Service Plan states R1’s needs include continence care, dressing assistance, medication management, shower assist, and special diet. See LIC9099-C page for more information. Page 1 of 3. Unfounded During interview on 10/29/2025, resident R1 stated to have not experienced a change in condition since arriving at the facility. During interview on 01/16/2026, ADM stated that R1 had already suffered a stroke prior to being admitted to the facility. Allegation - Staff are not meeting resident's medical needs. - UNFOUNDED During interview on 10/29/2025, R1 stated to regularly refuse medications. During interview on 10/29/2025, staff S1, a medication technician, stated that he/she has been assigned to provide R1 with medication during both morning and night shifts. S1 stated he/she has asked R1 if R1 has taken his/her medications, and R1 will say, “No.” S1 stated he/she will ignore S1 or say the medications are “nasty.” S1 stated the staff will document that R1 refused the medication and the medication was discarded. R1’s Medication Administration Record (MAR) from September 2025 states R1 refused medications from 09/01/2025 to 09/09/2025 and was out of the facility from 09/13-15/2025. R1’s MAR from October 2025 states R1 refused medications on 10/04/2025 and from 10/06/2025 to 10/20/2025. The entries 10/06/2025, 10/07/2025, 10/19/2025, and 10/20/2025 state, “MD/RP notified.” The entries for 10/11/2025 and 10/13/2025 have notes that state, “refused after multiple attempts.” The entries from 10/17/2025 have notes that state, “resident stated [he/she] didn’t want to take [his/her] medications, when asked for a reason why [he/she] doesn’t want medications [he/she] turned away and ignored my questions.” The entries on 10/20/2025 have notes that state, “Resident stated ‘I choose to be free.’” During interview on 01/16/2026, ADM stated R1 refuses staff services and care. Page 2 of 3. Allegation - Staff are not meeting resident's dietary needs. - UNFOUNDED R1’s Physician’s Report states R1’s Special Diet is “No Added Salt (NAS) diet, Mechanical Soft, Thin.” R1’s Physician’s Report states R1 can feed himself/herself. R1’s Service Plan states R1 “will be offered a mechanical soft diet.” The Special Diet Board, dated 07/03/2025, includes the names and photographs of residents with dietary needs of residents who have special diets. R1’s name, photograph, and apartment number are shown along with the note “Mechanical Soft.” During interview on 10/29/2025, R1 stated that he/she does not need assistance with feeding. R1 stated staff assist him/her with feeding. R1 stated he/she regularly refuses to eat. R1’s Daily Log records R1 refused meals on 10/09/2025 and 10/12/2025. On 10/29/2025, LPA Marrufo interviewed S2, lead wait staff. S2 stated he/she picks up food from R1 after meals. S2 stated R1 sometimes refuses meals. During interview on 01/16/2026, ADM stated staff ask R1 if they can help with feeding him/her, but R1 tells staff to leave the food next to him/her and he/she will eat it later. This agency has investigated the complaint allegations listed. Based on interviews and review of records, the CCLD has found that the complaint allegations are UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. This report was reviewed with Administrator Shantela Yadao and a copy of this report was provided. Page 3 of 3. END REPORTthe state’s words, verbatim · CDSS document, Jan 16, 2026 · control 26-AS-20251020085128

Allegation investigated: Facility staff are not properly addressing resident’s behaviors. Facility did not ensure the resident received an updated medical assessment after a change of condition.

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with the Administrator, Shantela Yadao and stated the purpose of today’s visit. On 6/26/2025, the Department received a complaint with the above allegations. On 7/2/2025, the Department conducted an initial investigation at the facility. On 8/25/2025, the Department conducted an additional investigation at the facility. Continuation on LIC 9099-C, Page 1 of 3. Unfounded Page 2 of 3. On 6/19/2025, the resident (R1) had an unwitnessed fall at the facility and facility staff called 911 and R1 was transported to the hospital for medical assessment. On 6/20/2025, the resident returned back to the facility with new medication orders. On 6/21/2025, the facility staff noticed a change of condition where R1 had behaviors wherein R1 was confused and was verbally aggressive towards facility staff and family members. The facility staff called 911 and law enforcement arrived and assessed the resident, and they did not deem the resident required Emergency Medical Transportation (EMT). Facility staff are not properly addressing residents’ behaviors. It was alleged the resident’s behavior expressed on 6/21/2025 was not being addressed by the facility staff. On 7/2/2025, LPA Rai interviewed 3 staff who are aware of the incident of 6/21/2025. Three out of three staff stated resident started having behaviors after R1’s hospitalization on 6/20/2025. Three out of three staff stated there was a change of condition on 6/20/2025 as R1 was hospitalized and medications were changed. Three out of three staff stated this was R1's initial behavioral expression on 6/21/2025 and they are working with R1’s family and R1’s physician to ensure R1 is being provided with the appropriate care. S1 stated R1’s physician was contacted regarding the incident on R1 and did not provide any new orders for facility staff to follow. Based on review R1’s progress notes, there were no documented notes of R1’s behavior prior to 6/20/2025. LPA Rai reviewed change of medication order during hospital discharge on 6/20/2025, R1’s physician discontinued 2 medications on R1’s medication list. Based on review of R1's Individual Service Plan from 6/29/2023 – 6/23/2025, the facility staff did not mention R1 having any behaviors prior to 6/23/2025. LPA Rai reviewed R1’s Individual Service Plan for 6/23/2025, wherein R1’s Agitation behavior and action plan for staff providing R1’s care needs, which includes for staff to call 911 when agitation becomes a safety concern. LPA Rai reviewed the communication note faxed to R1’s physician on 6/21/2025 and noted R1’s physician did not provide new orders. Page 3 of 3. Facility did not ensure the resident received an updated medical assessment after a change of condition. On 7/2/2025, LPA Rai interviewed 3 staff (S1-S3) who are aware of the incident of 6/21/2025. Three out of three staff stated R1 had an initial behavioral expression on 6/21/2025 and they are working with R1’s family and R1’s physician to ensure R1 is being provided with the appropriate care. S1 stated R1’s physician was contacted regarding the incident on R1 and did not provide facility staff with new orders or appointments for R1. S2 and S3 stated the facility staff called 911 on the day of 6/21/2025 and the law enforcement arrived and assessed the resident, and they did not deem the resident required Emergency Medical Transportation (EMT). S1 stated they reached out to R1's physician to update about R1's change of condition so R1's physician can determine if R1 required a medical assessment after the incident on 6/21/2025. S1 stated R1's physician responded to the update with no new orders or appointments for R1, so the facility staff continued to monitor R1 for any additional behavioral expressions or changes of condition. On 8/25/2025, LPA Rai interviewed 2 staff (S4-S5). S5 was not aware if R1 received an updated medication assessment after the incident on 6/21/2025. S4 stated he/she noticed a change in R1, but R1 was not assessed by physician after the incident on 6/21/2025. LPA Rai reviewed the communication note faxed to R1’s physician on 6/21/2025 and noted R1’s physician signed the document to acknowledge receiving the note and did not provide new orders or appointments for R1 to follow up from the incident on 6/21/2025. 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, Shantela Yadao and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 9, 2026 · control 26-AS-20250626171730

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced annual inspection and met with Executive Director (ED) Shantela Yadao. LPA stated the purpose of the visit. LPA toured the interior and exterior of the facility with ED to include the kitchen, resident rooms, dining room, bathrooms, 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 the refrigerator temperature at 40 degrees F and Freezer at -10 degrees F. LPA observed the medication storage area, 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, which were last inspected on 9/4/2025 by a third party vendor. The facility will provide an update on the 9/4/2025 report to CCLD with repairs that are scheduled. Fire extinguishers were last serviced on 8/14/2025. The facility emergency drill log was reviewed. The facility's last drill was on 8/7/2025. Page 1 of 2 LPA toured 10 resident bedrooms. All 10 resident rooms have a bed, functioning lights, dresser/table, bedding and space for personal belongings. LPA toured 10 resident bathrooms. All 10 bathrooms had hand soap, paper towels, functioning lights, and covered trash bins. LPA measured water temperatures in 10 resident bathrooms. 10 out of 10 water temperatures were over 120 F. The facility will have maintenance bring water temperature within 105 F to 120 F per Title 22 regulation. LPA reviewed 4 resident records. LPA reviewed 5 resident’s Centrally Stored Medication and Destruction Records (CSMDR’s). LPA reviewed 5 staff records. During inspection, LPA observed the resident dining area to be closed off with plastic coverings. ED stated the resident dining area is being remodeled as of 9/15/2025. ED stated the facility did not inform the Department of the remodeling of the resident dining area. ED stated the facility will submit a plan to the Department of a timeline of the remodeling by 9/19/2025. No deficiencies were cited during today's visit per California Code of Regulations Title 22. Two (2) Technical Violations were issued, see LIC9102 for more information. An exit interview was conducted with Executive Director (ED) Shantela Yadoa and a signed copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 15, 2025

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: POC

On 8/6/2025, Licensing Program Analyst (LPA) Steve Chang conducted an unannounced POC visit. LPA met with Executive Director (ED) Shantela Yadao.. LPA explained the purpose of the visit. On 8/5/2025, the facility was cited the following type A deficiency during a complaint investigation visit for the complaint 26-AS-20240812112833. The following code sections were cited on 8/5/2025, with a POC due date of 8/6/2025: 87464(f)(1). On 8/6/2025, LPA conducted a POC visit to clear the Type A citation. LPA received a copy of the facility's plan of corrections with the staff training. Resident R1 and R2 moved out the facility on 8/27/2024 and 6/5/2025 respectively. A copy of the Letter of Deficiencies Cleared letter was provided. No deficiencies cited during today's visit. This report was reviewed with ED and a copy of the signed report was provided.the state’s words, verbatim · CDSS document, Aug 6, 2025

Allegation investigated: Neglect/lack of supervision resulted in resident on resident altercation.

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation finding and met with Executive Director (ED) Shantela Yadao. On 8/12/2024, the department received a complaint regarding two residents (R1 and R2) having physical altercation in the memory care unit. On 8/21/2024, the Department conducted an initial investigation visit, conducted interviews with Executive Director, 3 staff (S1 - S3), two private caregivers (PC1, PC2), and residents (R1, R2), and requested copies of documents such as but not limited to physician’s report, appraisal needs and services plan, updated care plan and incident reports. Continue on LIC9099-C. Page 1 of 4. Substantiated On 8/21/2024, LPA interviewed executive Director (ED) Shantela Yadao. ED stated that on 8/3/2024, around 7:30AM, residents R1 and R2 were at the hallway of memory care unit. R1 grabbed R2's shirt when R2 tried to pass R1. R2 told R1 "leave me alone". R1 did not stop grabbing R1's shirt and R2 pushed R1 away which resulted in R1 falling to the ground. ED stated there were 3 caregivers (S1, S2, S4) helping residents in memory care unit at that time, and 1 LVN (S3) was on duty responsible for memory care unit at that time. ED stated caregivers rushed on site when heard the noise. The facility staff S1 called 911 immediately and R1 was sent to ER hospital due to head injury. R1 was discharged from hospital and returned to the facility at 2:30PM on the same day. ADM stated R1 and R2 live in the memory care unit of the facility, and each one has a one-on-one companion and both companions start at 8:00 AM. On 8/21/2024, LPA interviewed caregiver S1. S1 stated on 8/3/2024, around 7:30AM, he/she was assisting resident in room #125 and heard R2 in loud voice stating "Leave me alone ... don't touch me" . S1 stated he/she rushed out of room #125 to on site in the hallway across room #125 of the incident, he/she saw R1 was pulling R2's shirt and R2 pushed R1 away, who landed on his/her bottom to the floor and hit the head. S1 stated the altercation between R1 and R2 happened very quickly he/she tried to intervene, but it was too late. S1 stated caregivers S2 and S4 were assisting other residents in memory care unit. S1 stated caregiver S2 came to assist R1 with him/her to let R1 to sit on chair. S1 stated he/she called 911 and LVN due to R1 was bleeding on the head. S1 stated ambulance came and R1 was sent to hospital due to head injury. On 8/21/2024, LPA interviewed caregiver S2. S2 stated on 8/3/2024, around 7:30AM, he/she was assisting residents when he/she heard S1 screaming "Don't do that". S2 stated he/she paused assisting resident and rushed outside resident room to see what was going on. S2 saw R1 was on the floor with head bleeding. S2 stated S1 called 911 and LVN. R1 was sent to hospital due to head injury. On 8/21/2025, LPA interviewed LVN (referred as S3), who stated that on 8/3/2025, around 7:30AM, he/she received a phone call from S1. S3 stated S1 reported the incident of R1 and stating S1 already called 911. S3 stated police officers and ambulance came in around 5 minutes after he/she received the phone call from S1. S3 stated R1 was sent to hospital due to R1's head injury. Continue on LIC9099-C. Page 2 of 4. On 8/21/2024, LPA attempted to interview R1 at R1's room. R1 did not respond to LPA's questions regarding to the incident due to cognitive disorder. LPA observed that R1 was combative, refused and resisted assistance from staff S2 and his/her private companion (PC1). LPA interviewed R1's private companion (PC1) in R1's room, who stated R1 is combative with staff who are assisting R1 with his/her ADLs. PC1 stated R1 likes to go around grabbing things with his/her hand but has no cognition of what he/she is doing because of cognitive disorder. On 8/21/2024, LPA attempted to interview R2. R2 was unable to answer LPA's questions regarding the incident. LPA observed R2 was not combative and was compliant with staff and his/her private companion's (referred to as PC2) assistant. LPA interviewed PC2 who stated R2 is usually calm and friendly, and has no problem when being assisted with his/her ADLs. ADM stated on 8/3/2025, facility staff notified R1 and R2s' responsible parties of the incident. ADM stated a care conference was scheduled to discuss and develop a plan to prevent R1 and R2's engaging in future physical altercations and reached to an agreement that to provide a 24/7 private caregiver for R1 and a private caregiver from 7:00AM to 8:00PM every day for R2, and possible relocation plans for R1 and R2. Based on the review of the incident report dated 8/5/2024. On 8/3/2024, around 7:30AM, R1 and R2 were walking in the hallway of memory care unit and R1 grabbed R2. R2 pushed R1 away and R1 fell on the floor. Staff S1 came on site to assist R1, and S2 and S4 also came to assist R1 to sit on chair. R1 was sent to hospital due to injury. Based on the interview and documents reviewed including but not limited to incident reports, prior to this incident on 8/3/2024, there were 2 incidents occurred between R1 and R2 with similar scenarios on 6/4/2024 and 6/8/2024. On 6/4/2024, around 7:29AM, at the hallway in memory care unit, R1 and R2 were walking at the hallway of the memory care unit and R1 blocked R2. R2 tried to walk around but R1 grabbed R2. R2 pushed R1 away and R1 fell on the ground. R1 sustained laceration on the head and was sent to hospital. On 6/8/2024, around 11:15AM, at the dinning area of memory care unit, R1 slapped at R2 and R2 pushed R1 away. R1 fell down and hit the head. R1 sustained bleeding on the head and was sent to hospital. Continue on LIC9099-C. Page 3 of 4. Based on the review of R1's physician report dated on 2/6/2024, R1 has inappropriate behavior, aggressive behavior, and wandering behavior. Based on the review of R1's Individual Service Plan dated 6/8/2024, R1 has behavior of aggression, agitation and pacing. R1's Individual Service Plan specifies R1 constantly wanders in the hallway of memory care unit. R1 had incidents on 6/4/2024 and 6/8/2025 with the same resident. Both incidents included R1 pulling and pushing the resident and the other resident responded back by pushing R1 away, and caused R1 to have head injuries. R1's Individual Service Plan specifies redirect other residents from R1 if R1 becomes agitated and stay out of R1s' personal space when R1 gets agitated. After the previous incidents between R1 and R2 , the facility suggested families of R1 and R2 to hire private companion. Both R1 and R2 have private companions but start 8:00AM. This incident occurred around 7:30AM, at that time there were no private caregivers and there was no staff provide supervision to R1 and R2. This is the third incident with the same residents R1 and R2, and with the similar scenario. This incident caused R1 to sustain head injuries and was sent to hospital. Facility staff neglected and lack of supervision resulted in resident R sustained head injuries.. The Department has investigated the above allegation. Based on documents reviewed, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED. Citations noted today. Please see LIC9099-D. Exit interview was conducted with ED. A copy of the report was provide to ED. Page 4 of 4.the state’s words, verbatim · CDSS document, Aug 5, 2025 · control 26-AS-20240812112833

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(F)(1) · Plan of correction due date: Aug 6, 2025

87464 Basic Services(f) Basic services shall at a minimum include:(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on interview and record reviewed, The facility did not provide the necessary care and supervision to resident R1 and R2 to meet R1 and R2's care needs and leading to R1's multiple falls and sustained head injury which poses/posed an immediate Health, Safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 5, 2025

Plan of correction: Executive Director (ED) stated to submit a plan of correction by the POC due date and provide staff training to prevent the similar incidents to happen again. ED agreed to send the staff training log to CCL office.

Allegation investigated: Staff did not prevent resident from being harmed by another resident.

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver an investigation finding and met with Executive Director (ED) Shantela Yadao. On 6/7/2024, the Department received an complaint with the allegation that on 6/4/2024 staff did not prevent resident from being harmed by another resident. On 6/14/2024, the Department conducted an initial investigation visit. LPA requested physician reports, Appraisal Needs and Service plan of residents R1 and R2. LPA interviewed 2 residents (R1, R2) and 5 staff. Continue on LIC9099-C. Page 1 of 3. Unsubstantiated On 6/14/2024, LPA interviewed Executive Director (ED) Shantela Yadao. ED stated on 6/4/2024 early morning, he/she received a notice from staff regarding the incident between residents R1 and R2. ED stated based on the review of the surveillance camera footage, on 6/4/2024, around 7:30AM, residents R1 and R2 were walking at the hallway of the memory care unit and R1 blocked R2. R2 tried to walk around but R1 grabbed R2. R2 pushed R1 away and R1 fell on the ground. ED stated staff helped R1 to get up and called 911, and. R1 was sent to hospital. ED stated R2 is not an aggressive person. ED stated this is first incident between R1 and R2. On 6/14/2024, 12/23/2024 and 12/27/2024, LPA interviewed Director of Memory Care (DMC). DMC stated an incident occurred on 6/4/2024 early morning, after breakfast, between residents R1 and R2 at the hallway of memory care unit. DMC stated R1 grabbed R2 and R2 pushed R1 away. R1 fell on the ground, 911 was called and R1 was sent to hospital. DMC stated R1 returned to the facility from hospital on the same day. DMC stated after the incident, the facility requested both R1 and R2's families to hire private companion for R1 and R2. DMC stated R2 is a friendly person and not aggressive. On 6/14/2024 and 12/27/2024, LPA interviewed staff S1. S1 stated the incident occurred on 6/4/2025, early morning, after breakfast. S1 stated he/she was busy helping residents in memory care unit and all the staff in memory care unit were helping residents to be ready to transferred from memory care unit to activity room. S1 stated all residents were waiting to transfer to activity room. S1 stated he/She heard radio announced that a resident fell on the floor of the hallway in the memory care unit and asked staff to help immediately S1 stated he/she went to on site to help resident R1 immediately and called LVN and 911. S1 stated R1 was sent to hospital immediately. On 12/27/2024, LPA interviewed Director of Resident Service (DRS). DRS stated on 6/4/2024, around 7:30AM, staff were busy helping memory care resident to move to activity room, and resident were waiting to transfer to activity room. DRS stated resident R1 and R2 were walking in the hallway of the memory care unit. DRS stated suddenly R1 grabbed R2 when R1 and R2 passed each other. R2 pushed R1 away and R1 fell. DRS stated staff called 911 and R1 was sent to hospital. Continue on LIC9099-C. Page 2 of 3. Based on the review of the Law Enforcement Task Force Report dated 6/7/2024, on 6/4/2025, an incident occurred at the facility and caused resident R1 to obtain bodily injury and was sent to hospital. The incident was captured on video. Based on the footage of the camera system, on 6/4/2024, at 7:28AM, residents R1 and R2 were walking in the hallway of memory care unit and was trying to pass each other. At 7:29AM, R1 reached to R2 and R2 pushed R1 away and down on the ground in the hallway. At 7:30AM, R1 got back up and a staff was attending to R1. R1's injuries were determined to be non life threatening. A safe plan for R1 was put in place by the facility. Based on the review of R2's physician report dated 4/12/2023, R2 has no aggressive behavior. Based on the interview with staff, this is the first incident between R1 and R2, staff stated R2 is not aggressive. Based on the interview and record received, this is the first incident between resident R1 and R2. The incident occurred in suddenly when R1 and R2 tried to pass each other in the hallway of memory care unit and there were 4 caregivers at memory unit helping residents to be ready to transfer to activity room. The facility staff were monitoring through surveillance camera and the announced immediately to have staff to arrive to help R1. Staff arrived on site to help R1 within one minute to help resident. Based on the investigation, interview, records reviewed, the Department found that the above allegation is 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. Citations were noted today. Exit interview was conducted with ED. The report was provided to ED for review and signature. A copy of the report was provide to ED. Page 3 of 3.the state’s words, verbatim · CDSS document, Jul 7, 2025 · control 26-AS-20240607150519

Allegation investigated: The facts provided in the 30 day eviction notice for a resident is without foundation or merit.

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation finding and met with Executive DIrector (ED) Shantela Yadao. On 5/21/2024, the Department received a complaint with the allegation that the fact provided in the 30 day eviction notice for a resident is without foundation or merit. On 5/30/2024, the Department conducted an initial investigation visit. LPA interviewed ED, 5 staff (S1 - S5), and resident R1. LPA requested resident file documents including progress notes, appraisal needs and service plan. Continue on LIC9099-C. page 1 of 3. Unfounded The facts provided in the 30 day eviction notice for a resident is without foundation or merit: The allegation is that resident R1 denied the accusation specified on the 30 days eviction letter issued by the facility . Resident R1 was accused that on 4/18/2024, R1 made an inappropriate comment stating to push facility staff out of the window and pulled an Swiss knife out and pretended to stab facility staff. Resident R1 was accused on 5/7/2024, around 12:30PM, R1 lit something on fire in R1's bathroom, creating a large fire to set off the facility sprinkler system which resulted in serious water damage to the facility. The fire threatened the health and safety to the residents and staff at the facility. On 5/30/2024, LPA interviewed staff S1. S1 stated on 4/18/2024, he/she and staff S2 went to R1's room to fix R1's internet problem. S1 stated R1 stated “I wonder what would happen if you would fall from the window”. S1 stated R1 took out an Swiss army knife and took off the knife part of the Swiss army knife. LPA interviewed staff S2. S2 stated he/she went with S1 to fix R1's internet problem. S2 stated he/she heard R1 stated something about throwing something over the window. S2 stated R1 had a little knife, and then gestured his knife close to S1. S2 stated the knife was too close to S1. Based on the review of the incident report dated 5/9/2024, on 5/7/2024 around noon time, the facility fire alarm was activated. The fire panel indicated the source from room #337 of resident R1. Water was pouring out, flowing to the hallway. Fire fighters came in the facility and stated that it seems as if R1 was burning paper and got out of control and sprinkler was activated. Resident rooms next door as well as below on second floor and first floor were all affected as water leaked below. On 5/10/2024, LPA toured the facility. LPA observed R1's room #337 door frame in the bathroom and walls were black due to smoke. R1's apartments next door as well as below on 2nd and 1st floor were all affected as water leaked below and hallways. LPA toured the affected rooms 121B, 251, 334, 337 and 339. The rooms were used fans to dry out the water. Continue on LIC9099-C. Page 2 of 3. LPA interviewed Executive Director (ED). ED stated ED stated the facility took R1's lighters after the incident. On 5/20/24, the facility issued a 30 day eviction letter to R1 based on public safety concern of the incident occurred on 5/7/2024. On 5/30/2024, LPA interviewed staff S3 and S4. Both stated when they went to the third floor and entered R1's bedroom on 5/7/2024, they saw there was smoke in R1’s kitchen. LPA interviewed staff S5. S5 stated on 5/7/2024 he/she entered R1's room, and he/she did see some smoke and some char debris in the water. On 6/14/2024, LPA received an email from ED with a recording of voicemail that declaring no longer wants to pursue the complaint. On 6/27/2024, R1 moved out from the facility with R1's family member agreement. Based on the review of the fire fighter report dated 5/7/2024, the sprinkler was activated by room #337, and the water damage was observed to the rooms in the third floor, second floor and first floor. R1 did not comply with general policies of the facility that resident must not engage in conduct that poses a danger to self or others at the facility, must not be disruptive, must not create unsafe condition. The Department has investigated the above allegations. Based on the investigation, records reviewed, observation, 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 citations noted at today’s compliant investigation visit. Exit interview conducted with Executive Director (ED). This report was provided to review and for signature. A copy of this report was provided to ED. Page 3 of 3.the state’s words, verbatim · CDSS document, Oct 31, 2024 · control 26-AS-20240521084801

Allegation investigated: Staff are not administering resident's medication per physician's order.

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation finding and met with Executive Director (ED) Shantela Yadao. On 5/15/2023, the Department received a complaint that the facility staff are not administering resident's medication per physician order. On 5/24/2023, the Department conducted an initial investigation visit. LPA interviewed ED, Executive Assistant, Director of Resident Care, Medication Manager, resident R1 and R1's family member(FM). LPA requested Resident's discharge documents, doctor prescriptions, physician report, Appraisal Needs and Service Plan, May 2023 Medication Administering Records (MAR). Continue on LIC9099-C. Page 1 of 3. Unfounded Staff are not administering resident's medication per physician's order: On 5/24/2023, LPA interviewed Executive Director (ED). ED stated Med Techs administer medications to residents. ED stated Med Techs will retry 3 times if residents refuse the medications. ED stated Med Techs will document and report if residents refuse medications. LPA interviewed Director of Resident Service (S1). S1 stated resident R1 does not have any incident of missing medications. LPA interviewed Executive Assistant (S2). S2 stated he/she is not aware of that R1 has incident of missing medications. LPA toured resident room and interviewed resident R1. R1 was unable to exactly answer the questions. R1's family member (FM) stated R1 has neurocognitive impairment and he/she can help to answer the questions. LPA interviewed FM. FM stated on 5/7/2023 evening, he/she gave a bottle of medication to a staff (unknown name) in the facility hallway. FM stated based on R1's discharge document, the medication should be administered to R1 starting 5/8/2023. FM stated on 5/8/2023, he/she found the medication in the storage/medication room. FM stated on 5/8/2023, he/she met and talked to a nurse (S3) and the facility started to administer the medication to R1 on 5/13/2023. FM stated the facility did not administer the medication to R1 from 5/8/2023 to 5/12/2023. LPA interviewed Medication Manager (S4). S4 stated R1 does not have incident of missing medications. S4 stated the system does not have the medication for R1 from 5/8/2023 to 5/12/2023. S4 stated the system has the medication starting 5/13/2023, and the MAR shows the medication was administered to R1 starting 5/13/2023. S4 stated only nurses and medication manager can input the medications into the computer system. S4 stated Med Techs administer medications to resident based on the medication information in the computer system. S4 stated the medication for R1 was entered in the computer system on 5/13/2023, and was administered to R1 staring on 5/132023. S4 stated he/she did not receive any report that the facility received R1's medication on 5/7/2023. Continue on LIC9099-C. Page 2 of 3. LPA interviewed staff S3. S3 stated resident's family member cannot just bring the medication to the facility for resident. S3 stated the facility needs doctor's order or prescription to administer medications to resident. S3 stated even the over the counter medication that family member brings in for resident, the facility also needs the doctor order for resident. S3 stated R1's family member saw the medication (over the counter) in the medication room but not starting to administer medication to R1 is that the facility was requesting for resident's doctor or prescription for resident R1. Based on the interviews and document review, the facility did not receive the doctor order for the medication for R1 before 5/13/2023. The facility started to administer the medication to R1 starting from 5/13/2023.. The Department has investigated the above allegations. Based on the investigation, 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 citations noted at today’s compliant investigation visit. Exit interview conducted with Executive Director (ED). This report was provided to review and for signature. A copy of this report was provided to ED.the state’s words, verbatim · CDSS document, Sep 18, 2024 · control 26-AS-20230515102040

Allegation investigated: Staff did not adequately supervise resident resulting in resident sustaining a fracture while in care.

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation finding and met with Executive Director (ED) Shantela Yadao. On 7/11/2023, the Department received a complaint with the allegation that staff did not adequately supervise resident resulting in resident sustaining a fracture while in care. On 7/18/2023, the Department conducted an initial investigation visit. LPA interviewed 4 staff and requested Resident physician report, Appraisal Needs and Service Plan, Incident Reports. Continue on LIC9099-C. Page 1 of 3. Unsubstantiated Staff did not adequately supervise resident resulting in resident sustaining a fracture while in care: On 7/18/2023, LPA interviewed Executive Director Assistant (S1). S1 stated resident R1 can walk in the facility by self without help. S1 stated R1's family member, POA, agreed to place R1 in the facility assisted living unit. S1 stated R1 was assessed by the facility nurse and was admitted in the assisted living unit. S1 stated R1 had a fall in his/her bedroom on 5/28/2023, and was sent to hospital. S1 stated the facility sent the incident report to CCL office. S1 stated R1 was transferred to another facility after discharging from the hospital. LPA interviewed Director of Resident Services (S2). S2 stated R1 did not have pendant call button service to call or notify staff. S2 stated on 5/28/2023 around 8:00AM, R1 was found on the floor of his/her bathroom by a caregiver. S2 stated a facility nurse was noticed and came to evaluate R1 and R1 was sent to hospital. S2 stated R1 usually gets up around 7:00AM by self. LPA interviewed a caregiver (S3). S3 stated R1 behaved normally as usual before the incident. S3 stated on 5/28/2023, around 6:15AM, he/she checked R1 and found R1 was sleeping in the bed as usual. S3 stated R1 lived in a single room and usually gets up self without any help. S3 stated on 8/28/2023 around 8:00AM, he/she found R1 was on the floor of his/her bathroom. S3 stated he/she called thee nurse immediately, and thee nurse came to evaluate R1 immediately. S3 stated the nurse called 911 and R1 was sent to hospital. Based on the review of R1's incident report, on 5/28/2023 around 8:00AM, R1 was found on the floor of his/her bathroom and complained about pain on the left hip. R1 was sent to hospital. R1 sustained left hip fracture. Based on the interviews and record reviews, R1 usually gets up by self without any help and R1 was checked by staff twice within 2 hours from 6:15AM - 8:00AM. R1's fall on 5/28/2023 is a unwitnessed fall. The facility staff called 911 immediately after found R1 was on the floor, and R1 was sent to hospital. Continue on LIC9099-C. Page 2 of 3. 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.the state’s words, verbatim · CDSS document, Sep 18, 2024 · control 26-AS-20230711083943

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Steve Chang conducted an unannounced annual inspection visit and met with Executive Director (ED) Shantela Yadao. LPA reviewed 5 resident files and 5 staff files. LPA toured the facility inside and out with ED. LPA observed license, ADM Certificate, and personal rights posters in the facility. LPA toured the first floor. LPA inspected the lobby, living room, common restrooms, dining room, kitchen, laundry room, and resident rooms. LPA toured the second floor. LPA inspected the activity rooms, chemical storage room, nurse room, salon room and resident room. LPA toured the third floor. LPA inspected activity room, game room, laundry room, and resident rooms. The facility has a incident at 3:00AM today. The faucet of room 327 was broken. The water came out, room #327, #329, #330, #328, nurse office in the second floor and room #115 at the first floor are affected. The facility fixed the issue this morning. The affected rooms are got dried. LPA checked all the affected rooms, and they are without problems. The affected rooms are waiting to dry. ED stated they should be fine and recover back to normal around noon time today. The room temperature of the facility was at 72 degree F. The temperature of the refrigerator was observed at 40 degree F, and the temperature of the freezer was at 0 degree F. Hot water was measured at 106 degree F. Medication room and medication carts were observed locked. Chemical rooms was observed locked. Knives closet was observed locked. Continue on LIC809-C. Page 1 of 2. Fire extinguisher was serviced on 08/15/2024. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Fire alarm system was tested and was working fine. Carbon monoxide detector was observed running out of battery, the facility fixed it before LPA finished the inspection. LPA tested the door delay opening for the memory care unit and it was working fine. The memory care unit backyard and assisted living unit back yard were inspected. Both have the delay opening gates. Deficiencies noted today. See LIC809-D An exit interview was conducted with ED. This report was provided to ED to review. A copy of this report was provided to ED. Page 2 of 2.the state’s words, verbatim · CDSS document, Sep 12, 2024

Type of visit: Case Management - Incident

Licensing Program Analysts Steve Chang and Manuel Monter conducted an unannounced case management and met with Executive Assistant Yoliana Sanchez (EA). The purpose of today's visit was to open a complaint and get additional information regarding an incident report. LPAs interviewed EA and staff S1. EA provided LPA's with the police report case number. Both EA and S1 stated resident R1 was normal as usual. EA stated R1 was in hospice care before and graduated from hospice care in January 2024. EA stated staff S2 found R1 unresponsive in R1's bedroom. The facility called 911. Paramedics came in the facility and the police officers arrived also. LPAs requested R1's physician report and appraisal needs and service plan. Exit interview was conducted with EA. No deficiencies cited during today's visit. The report was provided to EA for signature. A copy of the report was provided to EA.the state’s words, verbatim · CDSS document, May 30, 2024

Type of visit: Case Management - Incident

Licensing Program Analysts (LPAs) Steve Chang and Manuel Monter conducted an unannounced case management- incident visit and met with Executive Director (ED) Shantela Yadao. On 5/10/24, the Department received an incident report from the facility that on 5/7/24 at noon, the facility fire alarm and fire sprinkler system was activated in the AL unit on the 3rd floor. Fire Department (FD) responded upon activation of fire alarm in the facility. FD determined that R1 was burning a paper and it got out of control. No major fire damage reported other than R1's door frame in the bathroom and walls were black due to smoke. R1's apartments next door as well as below on 2nd and 1st floor were all affected as water leaked below and hallways. All residents were having lunch when the incident happened. All residents including R1 were evacuated out of the facility safely. No injuries and/or hospitalization reported. No known media attention. LPAs toured the affected rooms 121B, 251, 334, 337 and 339. The rooms were used fan to dry out the water. ED stated the rooms will be back to normal on 5/13/24 Monday. LPAs interviewed resident R1. R1 denied he/she made the fire. R1 stated he/she did not know what happened. ED stated the facility took R1's lighters and update R1's care plan. LPAs requested R1's physician report, Appraisal Needs and Service Plan. ED stated no one got injury. ED stated the facility will update CCL office. ED stated he/she will send follow up action plan to LPA. Exit interview was conducted with ED. The report was provided to ED for signature.the state’s words, verbatim · CDSS document, May 10, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced Case Management - Incident visit and met with Administrator (ADM) Shantela Yadao. On 11/06/2023, LPA Chang interviewed staff S1- who stated that Resident (R1) was found on the floor of R1's bedroom on 11/3/2023 at 7:00AM in Assisted Living found by staff (S2). 911 was called immediately, around 7:15AM on 11/3/2023. R1 was assessed by paramedics, R1 was pronounced dead at 7:25AM. LPA interviewed 4 Staff (S1 - S4) and Administrator (ADM). LPA interviewed two Family members (FM1, FM2) of resident (R1). LPA obtained R1's Physician Report, Medication list and Care Plan and notes. 4 Out of 4 staff stated that R1 was weak due to cancer and was on oxygen 24 hours due to short of breath. ADM stated that R1 was seen on 11/3/02023 at 4:50AM by a NOC shift staff (S5) in his/her bedroom and was fine. On 11/3/2023, at 7:00AM, R1 was found on the floor unresponsive of his/her bedroom. Continue on LIC809-C. Page 1 of 2. Both Family members of R1 stated R1 was getting weaker, and his/her medical/health condition was declining. Both stated they don't have any complaint against the facility; they were supposed to have a meeting with the facility and hospice care agency today, 11/6/23. This case needs further investigation. ADM will update CCL office when R1's death certificate is available. Exit interview was conducted with ADM. The report was provided to ADM for signature. A copy the report was provided to ADM. Page 2 of 2.the state’s words, verbatim · CDSS document, Nov 6, 2023