Country Crest Assisted Living

Type of visit: Case Management - Incident

08/18/2026 02:45 PM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with Executive Director Irene Davis. Today’s visit is regarding two incident reports that were submitted to licensing regarding incidents that occurred in July and August 2026 involving the same resident. On 07/04/2026 Resident 1 (R1) could not be found by their wife inside the facility’s assisted living portion of the facility. R1 was found outside in the parking lot walking to their car with no shoes on. R1 stated they were looking for their shoes. R1 was on hospice at the time of the incident and was therefore on 1-hour checks at the time of the incident. On 08/03/2026 R1 had a witnessed fall in their room. R1 was examined by on call hospice nurse who initially failed to observe bruising and lump on R1’s forehead. R1 experienced increased confusion. R1 was transported to hospital for evaluation per physicians instructions. During the investigation it was learned that R1 was transported to the ER per their physician’s orders at 10:00 AM the same day. R1 was diagnosed with fall and UTI at the ER. The hospital conducted CT scan and confirmed that R1 did not have a brain bleed. R1 returned to the facility at 2:00 AM on 08/04/2026. In order to prevent this from occurring the facility has updated R1’s care plan to include 2 hour checks and stand by assist for shower and hygiene. Since the incidents R1 has moved to the secured memory care unit No deficiencies were cited as a result of today’s visit. Exit interview conducted and a copy of the report was provided to with Executive Director Irene Davis.the state’s words, verbatim · CDSS document, Aug 18, 2026

Allegation investigated: Staff do not answer the facility phones.- SUBSTANTIATED Facility staff do not respond to residents’ calls in a timely manner. - SUBSTANTIATED Staff do not ensure the residents’ toileting needs are met. - SUBSTANTIATED

/30/2026 09:20 AM Licensing Program Analyst (LPA) Rebecca Knight made an unannounced visit to the facility and met with Executive Director Irene Davis. The purpose of this visit was to deliver the results of a complaint investigation. During the course of the investigation LPA conducted interviews, toured the facility and reviewed documents Continued on LIC9099-C Substantiated Staff do not answer the facility phones. - SUBSTANTIATED It was reported that over a period of two hours R1’s responsible party (RP) called the facility seven different times to notify staff that R1 required assistance but staff did not answer the phone. RP determined this due to R1 having a video camera in their room which the RP was monitoring. All staff who were interviewed stated they were not aware that staff did not answer the phone when the RP was trying to speak with the facility. Staff stated that sometimes the phone will only ring once but staff return calls to whomever leaves a voice mail. Executive Director stated When the resident’s family called the facility there was no answer and it took a couple of hours until staff returned the call. ED told staff if they are busy and cannot answer they are to return the call as soon as possible. ED stated that staff spoke with the RP at 5:00 AM. This allegation is substantiated. Facility staff do not respond to residents’ calls in a timely manner. - SUBSTANTIATED It was reported that on 05/08/2026 08:00 PM R1’s family member saw staff (via video camera in the resident’s room) bring R1 into their room and place R1 in their recliner with their feet up, and turn the television on loud. Staff walked out of the room and no staff came to check on R1 for nine hours, which left R1 struggling and trying to get out of the recliner. R1 called for help, and staff did not come and help R1. Witness interviews confirmed that R1 was placed in a recliner in their room, was unable to get out of the recliner for hours. During staff interviews it was learned that R1 had a call light pendant but never used it. Executive Director stated A staff member thought R1 could get out of the chair in their room on their own because this staff saw R1 getting out of the chair in the common area which has a different type of recliner. ED told staff that they are not to put the resident’s feet up because the chairs don’t have a lever to lower them. It was determined that R1 was left in the recliner in their room with their feet up, calling for help and unable to get out of the chair. This allegation is substantiated. Staff do not ensure the residents’ toileting needs are met. - SUBSTANTIATED It was reported that staff left Resident 1 (R1) in their room and did not check on R1 for nine hours, during which time R1 could not use the restroom. LPA reviewed LIC602 Physicians Report for R1 which states that R1 is independent with toileting. Needs and Services Plan states that R1 is standby assist for toileting due to fall risk. Witness interviews confirmed that R1 was placed in a recliner in their room, was unable to get out of the recliner for hours. During staff interviews it was learned that R1 is mostly independent with toileting but does require reminders and assistance to get to the bathroom. Executive Director stated R1 knew when they had to toilet, staff would remind R1 but R1 typically went to the toilet every 20 minutes and staff would walk with R1 because they were unsteady sometimes. A staff member thought R1 could get out of the chair in their room on their own because this staff saw R1 getting out of the chair in the common area which has a different type of recliner. It was determined that R1 was left in the recliner in their room with their feet up, calling for help and unable to get out of the chair which resulted in R1 not being toileted. This allegation is substantiated, Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview conducted and a copy of the report was provided to Executive Director Irene Davis Resident sustained multiple bruises and injuries due to staff neglect. - UNSUBSTANTIATED It was reported that Resident 1 (R1) experienced multiple falls which resulted in injuries. LPA reviewed the following photographs of R1: R1 with a lateral incisor to the right of the central incisor. A separate photograph shows the lateral incisor to be diminished to a small stub which is usually consistent with cosmetic dentistry preparation for a crown or veneer. Photograph of R1 shows R1 smiling with bottom teeth present. Photograph of left foot with dry skin, fungus, dried blood on large left toenail. LPA did not receive any photographs of bruising to R1. LPA reviewed the following incident reports: 04/19/2026 R1 was getting up off the couch in the common area and slid to the floor, no injuries reported. 04/21/2026 Staff heard a noise from R1’s room, upon response found R1 on the floor, assessed for injury none found. 04/25/2026 R1 slapped another resident on their arms and slapped a staff member. No injuries noted. 04/26/2026 EMS was called to assess R1 for shoulder injury per family’s request. EMS assessed and did not transport R1. 05/09/2026 R1 was found on the floor of another resident’s room. R1 stated they did not fall but put themselves on the floor. Staff assessed R1 for injuries and found none. 05/22/2026 R1 had a witnessed fall in the common area during which R1 struck their head. EMS was called and transported R1 to hospital where R1 was treated for a head injury. LPA reviewed LIC602 Physician’s Report dated 04/15/2026 which states under history of skin breakdown that R1 picks at their scabs. During staff interviews it was learned that R1 spent the majority of their time in the common area and was usually in line of sight for staff. All staff stated that R1 is a habitual “picker” which resulted in the loss of the cap that was on R1’s lateral incisor. Staff witnessed R1 remove that cap from their tooth while eating and handed it to staff. Executive Director stated R1 had a scraped knee as a result of a fall but an MRI and x-ray showed no injury. It was determined that R1 experienced three documented falls while living at the facility. R1 was assessed for injury after each fall, 1 of 3 falls resulted in injury to R1 when they struck their head in the common area and were transported via EMS to hospital for treatment. This allegation is unsubstantiated. Continued on LIC9099-C Staff did not notify authorized representative of incident.- UNSUBSTANTIATED It was reported that R1’s family was only notified twice that R1 had received injuries throughout the entire time that R1 lived at the facility. LPA reviewed admission agreement for R1 dated 04/17/2026 which has R1’s spouse as the legal responsible person (RP) for R1. LPA reviewed an email that was sent to the Executive Director on 05/12/2026 which includes a request for a specific family member to be notified of all incidents and changes related to R1. LPA reviewed a total of six incident reports for R1 that were submitted from 04/19/2026 through 05/21/2026. 5 of 6 incident reports indicate no injuries resulted. RP was notified about 4 of the six incidents. One incident report includes injury to R1, RP was notified of this incident. 5 of 7 staff stated the RP was informed of falls and other incidents while R1 lived at the facility. 2 of 7 staff did not know if the RP was notified. Executive Director stated the RP for R1 is their spouse who requested that we call another family member. It was determined that the RP for R1 remained their spouse who was informed of all incidents prior to 05/12/2026 when staff were notified to call another family member. Five incidents occurred prior to 05/12/2026 and one incident occurred after this date, the alternate family member was informed of this incident. This allegation is unsubstantiated Continued on LIC9099-C Staff did not address a resident's change in medical condition in a timely manner. - UNSUBSTANTIATED Upon review, LPA could not locate any documentation or indication that R1 experienced a change in medical condition during the time they lived at the facility. All staff that were interviewed stated that R1 had not had a change in medical condition during the time they lived at the facility. Executive Director stated that R1 was getting used to living at the facility and was becoming more comfortable with their surroundings right before they moved out of the facility. If anything, their condition had improved. It was determined that R1 did not have a change in medical condition during the time they lived at the facility. This allegation is unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of of evidence to prove that the alleged violation occurred, and the findings are UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted and a copy of the report was provided to executive director Irene Davis.the state’s words, verbatim · CDSS document, Jul 30, 2026 · control 59-AS-20260602154418

From the deficiency page — Deficiency type: Type B · Section cited: CCR 7468.1(a)(9) · Plan of correction due date: Aug 13, 2026

7468.1(A)(9) Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (9) To have communications to the licensee from their representatives answered promptly and appropriately. This requirement was not met as evidenced by: Based on interviews the licensee failed to ensure that staff answered the phone for 2 hours when a resident’s family attempted to contact the facility by telephone multiple times to alert staff that the resident required assistance as seen on video cameras in resident's room. This poses a potential health, safety or personal rights risks to residents in care.the state’s words, verbatim · CDSS document, Jul 30, 2026

Plan of correction: Licensee agrees to conduct staff training on the requirement to answer telephone calls promptly. Licensee shall submit staff training sign in sheet as proof of correction.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Aug 13, 2026

87411(a) 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. This requirement was not met as evidenced by: Based on interviews staff did not respond to a resident’s calls for care nor did staff check on the resident to see if they required assistance in a timely manner. This poses a potential health, safety or personal rights risks to residents in care.the state’s words, verbatim · CDSS document, Jul 30, 2026

Plan of correction: Licensee agrees to conduct staff training concerning the requirement to check on residents during the night to ensure their needs are met. Licensee shall submit staff training sign in sheet as proof of correction.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.2(c) · Plan of correction due date: Aug 13, 2026

Health and Safety Code section 1569.2(c) provides: (c) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care. This requirement is not met as evidenced by: Based on interviews staff placed R1 in a recliner that they could not get up from independently and did not check on R1 for several hours which prevented R1 from using the restroom. This poses a potential risk for residents in care.the state’s words, verbatim · CDSS document, Jul 30, 2026

Plan of correction: Licensee is to submit a plan outlining how facility will conduct checks of all residents throughout the night. Licensee shall submit this plan to LPA for review as proof of correction.

Allegation investigated: Lack of staff supervision resulting in resident sustaining fracture. - UNFOUNDED Staff did not respond to resident's call light in a timely manner. - UNFOUNDED Staff did not report incident to responsible party. - UNFOUNDED

/30/2026 09:10 AM Licensing Program Analyst (LPA) Rebecca Knight made an unannounced visit to the facility and met with Executive Director Irene Davis. The purpose of this visit was to deliver the results of a complaint investigation. During interviews it was learned that the resident that the complaint concerns has never lived at the facility. This complaint is unfounded. This agency has investigated the complaint alleging a personal rights violation. We have found the complaint was UNFOUNDED, meaning that the allegations qre false, could not have happened, and/or is without a reasonable basis. Nothe state’s words, verbatim · CDSS document, Jul 30, 2026 · control 59-AS-20260721155220

Type of visit: Required - 1 Year

05/21/2026 12:45 PM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with Executive Director Irene Davis and explained the purpose of the visit. LPA Knight and the Executive Director toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to assisted living and memory care sections of the facility including resident rooms, common areas, activity rooms, laundry room, bathrooms, kitchen, storage areas, and outdoor patios. Staff and resident files were reviewed. All employees requiring background checks are cleared. Medications were reviewed. Medication is secured. There is a schedule of recreational activities planned for the residents. The facility was observed to be at a comfortable temperature. Common area was clean and in good repair. All bedrooms had required furniture, bedding, and lighting. Kitchen was clean and in good repair. Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. Fire extinguishers fully charged and inspected. Johnson Control comes in quarterly to inspect the entire community. The fire alarm, sprinklers and smoke detector systems are inspected annually in conjunction with Otis elevators. There are no pools/bodies of water are on premises. Emergency evacuation drills are conducted twice a year and fire drills quarterly. The facility also conducts elopement drills quarterly. Continued on LIC809-C LPA observed pine needles and debris collected on exposed roofing areas from the second and third floors. This debris needs to be removed from these areas and any other areas of the facility roof where debris is present. A deficiency is being cited on the attached LIC809-D in accordance with California Code of Regulations, (Title 22). Appeal rights were provided. Exit interview conducted and copy of report was provided to administrator Irene Davis.the state’s words, verbatim · CDSS document, May 21, 2026

Allegation investigated: Insufficient staffing to meet residents’ needs. - UNSUBSTANTIATED New staff do not have the required training before working independently. - UNSUBSTANTIATED

/21/2026 11:45 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to deliver the results of a complaint investigation. LPA met with Executive Director Irene Davis and explained the purpose of the visit. During the cours of the investigation LPA conducted interviews and reviewed documents. Continued on LIC9099-C Unsubstantiated Insufficient staffing to meet residents’ needs. - UNSUBSTANTIATED It was reported that resident needs are not met to include toileting, two-person assists, medication passed late, residents not being brought to dining room for meals due to insufficient staffing. LPA reviewed staffing schedule for January 2026. Combining all staff on duty for the assisted living and memory care units, the AM shift had an average of 2 med techs and 3 or 4 care staff. PM shift had 2 med techs and 3 care staff. NOC shift had 1 med tech and 2 care staff. These numbers reflect any staff call outs being accounted for in the totals. LPA interviewed six staff. 4 of 6 staff stated the facility struggles with staff calling out. 3 of 6 staff stated there are not enough staff on shift to provide timely toileting assistance or lift residents who require a two person assist. 2 of 4 staff stated if a med tech is being utilized for care giving tasks the medications are sometimes passed late. All staff stated that residents are brought to the dining room timely for meals. During interviews staff did not provide specific instances where care was not provided timely to residents as a result of insufficient staffing. ED stated the facility schedules 1 med tech and 2 care givers for each shift and each floor, assisted living and memory care. When staff call out the facility has one staff person floating in between floors. If the facility is “staff challenged” the ED or a manager will come in to assist on the floor. ED also stated there was one day in 2026 during a PM shift that all staff called out. ED stated that they came in and covered the shift and the staff who were already working from the AM shift stayed and worked through the PM shift that day. Overtime is paid to any staff who work over their scheduled shift. It was determined that facility generally has an acceptable staffing schedule and when staff call out management does come in and assist. In addition staff will chose to work overtime which they are compensated for. This allegation is unsubstantiated. Continued on LIC9099-C New staff do not have the required training before working independently. - UNSUBSTANTIATED It was reported that the facility is working new staff by themselves without proper training. LPA reviewed online training documentation for two new staff who had been hired in January 2026. Both staff completed online training: Total hours online training for care staff is 40, med techs completed 60 hours. LPA reviewed competency verification test results for the two staff. 5 of 6 staff stated that new staff get the required training they need. ED stated they meet with new staff to see if they need anything else and some will say they need more training. Recently the only one staff that said anything said they wanted more training with transfers so the staff was given more training. This allegation is unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted and a copy of the report was provided to Executive Director Irene Davis.the state’s words, verbatim · CDSS document, Apr 21, 2026 · control 59-AS-20260211145441

Type of visit: Case Management - Incident

03/12/2026 10:45 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with Executive Director Irene Davis. Today’s visit is regarding an incident report that was submitted to licensing on 01/19/2026. On 01/17/2026 10:50 PM Resident 1 (R1) was found on the floor in the hallway in front of their bathroom. R1 staled that they were experiencing pain In !heir left shoulder hip and knee. EMS was called and transported R1 to the local hospital for further evaluation. R1 was diagnosed with fracture of libial osteophyte. R1 was advised to wear an immobilizer at all times except when bathing. No weight bearing on right leg until orthopedist was seen, follow up with orthopedic clinic. During the investigation it was learned that R1 was not always complaint with wearing the prescribed brace. In order to prevent this from occurring again the facility has updated the care plan for R1 to include standby assisting for dressing, toileting and other ADLs to include more hands-on assistance for bathing. R1 was advised by physical therapy and their physician to use a wheelchair with staff following and a four-wheel walker with standby assistance. No deficiencies were cited as a result of today’s visit. Exit interview conducted and a copy of the report was provided to with Executive Director Irene Davis.the state’s words, verbatim · CDSS document, Mar 12, 2026

Type of visit: Case Management - Incident

12/05/2025 12:00 PM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with Executive Director Irene Davis. Today’s visit is regarding an incident report that was submitted to licensing regarding an incident that occurred on 11/08/2025. It was reported that on 11/08/2025 Resident 1 (R1) reported to Staff 1 (S1) Resident 2 (R2) had hit them in the head with a pumpkin. Both R1 and R2 are memory care residents. This was an unwitnessed incident and R1 was unable to provide any further details. R1 was found to have a bump on their head. S1 called EMS for medical evaluation. R1’s family refused to have R1 sent to hospital for evaluation. Report was made to local police department and long-term care ombudsman. During the investigation it was learned that there have been no further incidents between these two residents. In order to prevent this from happening again the facility has the activities director coming in a later shift so the residents are kept busier and she can provide one to one supervision if needed and redirect. Hospice has reviewed R2’s medication to make sure their pain and anxiety are being managed properly in case this was an influencing factor. No deficiencies were cited as a result of today’s visit. Exit interview conducted and a copy of the report was provided to Executive Director Irene Davis.the state’s words, verbatim · CDSS document, Dec 5, 2025

Allegation investigated: Staff do not ensure staff meet training requirements. - UNSUBSTANTIATED Staff does not ensure resident's files are properly stored. - UNSUBSTANTIATED

/06/2025 11:15 AM Licensing Program Analyst (LPA) Rebecca Knight made an unannounced visit to the facility and met with administrator Irene Davis. The purpose of this visit was to deliver the results of a complaint investigation. During the course of the investigation LPA toured the facility, conducted interviews and reviewed documents. Continued on LIC9099-C Unsubstantiated Staff do not ensure staff meet training requirements.-UNSUBSTANTIATED It was reported that some caregivers do not have all the training hours to be working on the floor. LPA observed a competency verification form that is filled out by the new employee in the first four days of employment as they complete each training and is verified by the Business office manager. This allegation is unsubstantiated. Staff does not ensure resident's files are properly stored. - UNSUBSTANTIATED It was reported that resident's files are not locked away in a cabinet. On 09/28/2025 LPA toured the facility and observed the door to the business office to be locked, this ensured that resident and staff files are properly secured. This allegation is unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted and a copy of the report was provided to Executive Director Irene Davis.the state’s words, verbatim · CDSS document, Nov 6, 2025 · control 59-AS-20250926083648

Type of visit: Case Management - Incident

11/06/2025 09:40 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with Executive Director Irene Davis. Today’s visit is regarding an incident report that was submitted to licensing regarding an incident that occurred on 10/05/2025. It was reported that on 10/05/2025 Resident 1 (R1) and Resident 2 (R2) went on an outing and R2 reported to staff that R1 became angry and grabbed R2 by their shoulder while they were in a grocery store. R2 yelled for help and asked someone to call the police. R2 got into the vehicle with R1. R2 stated that prior to this event R1 had been driving erratically and kept asking R2 where they were and why they were there. R1 stated they did not know where they were supposed to be. R2 stated that R1 nearly rear-ended another care and was revving the engine of the vehicle. R2 got out of the vehicle at a red light, R1 was grabbing R2’s arm and said they told R2 they were looking for their gun in the vehicle and warned R2 they had better get back In the vehicle. R2 walked back to the grocery store, called the facility, and asked for someone to come and pick them up. When staff answered the phone, R2 was crying hysterically, asked for help, and asked them to come and pick R2 up. During the investigation it was learned that R1 and R2 had just moved into the facility four months prior to the incident. R1 had moved into the facility from skilled nursing and as their health improved while living at the facility decided that they wanted to live independently in their own home. R1 was having difficulty adjusting to living in the facility. Due to this the facility enlisted the services of a behaviorist for R1 to receive support services. After the incident the facility reported to Adult Protective Services, local police department, and the ombudsman. R1 and R2 moved out of the facility back to their home in October 2025. No deficiencies were cited as a result of today’s visit. Exit interview conducted and a copy of the report was provided to Executive Director Irene Davis.the state’s words, verbatim · CDSS document, Nov 6, 2025

Type of visit: POC

11/06/2025 10:15 AM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with Executive Director Irene Davis. The purpose of this visit was to obtain current status on the items that LPA issued a physical plant citation for on 09/30/2025. LPA and ED toured the facility together and LPA made the following observations: Licensee does not ensure facility air conditioner is in good repair. During today's visit LPA observed that the temperature in the common area and office to be 73 degrees F. ED stated that the facility has ordered and received replacement air conditioning units to be installed in the first-floor common area and office on 11/14/2025. This installation will take one week to complete. LPA observed replacement units on premises. Staff does not ensure facility flooring is in good repair. During today's visit LPA observed the flooring has been replaced in the resident room. Staff does not ensure facility sewage is in good repair. During today's visit LPA learned / observed that the facility has re-routed the drain under the dishwasher and fixed the pipe that was the issue and the drains have been treated. No odor was observed during the visit. Continued on LIC809-C Staff does not ensure facility is free of insects. During today's visit LPA observed no insects in the facility. The facility has increased their pest control service to every week instead of bi-weekly. Flood damage in the elevator room to include water stained linoleum, patches of missing linoleum, possible mold damage, and the bottom foot of sheet rock missing from one wall. During today's visit LPA observed the sheet rock had been replaced in the elevator room and the hole is sealed. Linoleum has been cleaned in the elevator room and the linoleum has been replaced in an adjoining business office. Floors are sticky throughout the facility. During today's visit LPA learned /observed all floors to be clean and not sticky. Housekeeping staff has been instructed to follow a new ratio of cleaning products to clean the floors as the incorrect ratio was being used previously which caused the floors to be sticky. LPA will continue to monitor. The deficiencies that were issued on 09/30/2025 have been cleared. No deficiencies were issued as a result of today's visit. Exit interview was conducted and a copy of the report was provided to Executive Director Irene Davis.the state’s words, verbatim · CDSS document, Nov 6, 2025

Allegation investigated: Physical plant violations - SUBSTANTIATED

/30/2025 03:00 PM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a complaint investigation. LPA met with Angel Medrano business office manager and explained the purpose of the visit. LPA toured the facility, and conducted interviews during the visit. Continued on LIC9099-C Substantiated Physical plant violations - SUBSTANTIATED During the visit LPA toured the facility and made the following observations: It was reported that the licensee does not ensure facility air conditioner is in good repair. During a tour of the facility LPA observed that the first floor was very warm in the common area and office area. LPA took temperature readings that ranged between 82 and 85 degrees F. The air conditioning needs to be repaired. Staff does not ensure facility flooring is in good repair. LPA observed that 1 resident room had kitchen flooring that is buckled and damaged. This flooring needs to be replaced. Staff does not ensure facility sewage is in good repair. LPA observed floor drains in the main kitchen to be emitting a strong odor of sewage. Staff does not ensure facility is free of insects. LPA observed gnats to be flying around in the common areas, dining room,resident rooms, and kitchen in the assisted living portion of the facility. On the memory care portion of the facility LPA observed gnats in the common area and small kitchen areas. LPA observed dead cockroaches in the drawers of the coffee bar on the first floor. LPA observed a live cockroach and a dead cockroach in the elevator room. LPA observed two sticky traps in the memory care kitchen that had multiple cockroaches on them. LPA observed flood damage in the elevator room to include water stained linoleum, patches of missing linoleum, possible mold damage, and the bottom foot of sheet rock missing from one wall. LPA observed floors to be sticky throughout the facility. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview conducted and a copy of the report was provided to Angel Medrano.the state’s words, verbatim · CDSS document, Sep 30, 2025 · control 59-AS-20250926083648

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Oct 14, 2025

87303 (a) Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This was not met as evidenced by: LPA observed common area to be too warm, gnats flying in all areas of the facility, dead and alive cock roaches in common area, memory care kitchen and utility room, 1 resident room flooring in disrepair, sewage smell in the main kitchen, flood damage in the elevator utility room sticky floor throughout the facility.the state’s words, verbatim · CDSS document, Sep 30, 2025

Plan of correction: Licensee agrees to submit timeline in which all repairs will be completed to LPA as proof of correction by 10/14/2025. As the repairs are completed the licensee shall update LPA by submitting invoices and photographs of the repairs. Licensee agrees to remediate the gnat and cockroach infestation immediately and will submit pest control invoices to LPA as proof of correction. LPA will follow-up with visits to ensure the repairs / pest control / cleaning have been completed.

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

05/28/2025 12:00 PM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with Executive Director Irene Davis. Today’s visit is regarding two incident reports that were submitted to licensing regarding incidents that occurred on 04/15/2025 and 05/22/2025. Both of these incidents resulted in residents sustaining fractures related to falls that occurred in the facility. On 04/15/2025 Resident 1 (R1) pushed their PHB was complaining of left hip pain and wanted to go to the hospital to be checked out and get x rays. EMS was called and resident was transported to local hospital for evaluation. R1 was admitted to hospital with a diagnosis of hip pain and a fractured sacrum. During the investigation it was learned that on 3/04/2025 R1 was walking their dog and fell. R1 was sent out to hospital for evaluation and sent back with pain medication. On 04/07/2025 R1 had bruising due to an unwitnessed fall and was sent out again with no findings. On 04/15/2025 R1 had unmanaged pain and was sent out to the hospital, and was diagnosed with fractured sacrum. R1 was still experiencing pain so the facility sent R1 back to the hospital and they were discharged with stronger pain meds, home health, and physical therapy referral. Continued on LIC809-C On 05/22/2025 Resident 2 (R2) pushed their pendant and when staff arrived they found R2 on the floor in their bathroom. R2 stated they were attempting to transfer themselves and fell. R2 was assessed for injury and was found to have two skin tears on their left hand. R2 complained left hip pain and left knee pain. EMS was called and R2 was transported to hospital for evaluation and subsequently admitted with diagnosis of left hip fracture. During the investigation it was learned that R2 normally does transfer themselves during the day. In the morning R2 is assisted by staff to get out of bed, get dressed, and brush their teeth due to being in a wheelchair. That morning R2 attempted to transfer themselves and did not lock one side of their wheelchair and subsequently fell. R2 is currently hospitalized and scheduled for surgery. It is anticipated that R2 will be transferred to skilled nursing after surgery for rehabilitation. In order to prevent this from occurring the facility will conduct a fall prevention training with all staff. Administrator will submit a copy of the facility’s fall prevention plan to LPA. LPA referred administrator to ​​​​​​​​​StopFalls Sacramento Coalition for additional resources in fall prevention. https://dhs.saccounty.gov/PUB/StopFallsSacramento/Pages/Stop-Falls-Sacramento-Coalition.aspx No deficiencies were cited as a result of today’s visit. Exit interview conducted and a copy of the report was provided to with Executive Director Irene Davis.the state’s words, verbatim · CDSS document, May 28, 2025

Type of visit: Required - 1 Year

05/01/2025 09:00 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with Executive Director Irene Davis and explained the purpose of the visit. LPA Knight and the Executive Director toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to assisted living and memory care sections of the facility including resident rooms, common areas, activity rooms, laundry room, bathrooms, kitchen, and storage areas. Staff and resident files were reviewed. All employees requiring background checks are cleared. Medications were reviewed. Medication is locked in locked med room. There is a schedule of recreational activities planned for the residents. The facility was observed to be at a comfortable temperature. Common area was clean and in good repair. All bedrooms had required furniture, bedding, and lighting. Kitchen was clean and in good repair. Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. Fire extinguishers fully charged and inspected. Johnson Control comes in quarterly to inspect the entire community. The fire alarm, sprinklers and smoke detector systems are inspected annually in conjunction with Otis elevators. There are no pools/bodies of water are on premises. Last emergency evacuation drill was conducted on April 21, 2025, the facility has been conducting fire drills quarterly. LPA requested the following documents that need to be updated in the facility file: LIC500 Personnel report, Current liability insurance. No deficiencies are being cited as a result of today's inspection. Exit interview conducted and copy of report was provided to administrator Irene Davis.the state’s words, verbatim · CDSS document, May 1, 2025

Type of visit: Office

On this day at 11 am, a meeting was conducted by Assistant Program Administrator (APA) Stacy Barlow to verify Chapter 7 Bankruptcy Report filed by the Pacifica Senior Living as reported by the media. Present during the meeting are: Shelley Grace - Assistant Branch Chief, CCLD Craig Lundgren - Legal Counsel, CCLD Carl Knepler - Chief Executive Officer, Marlene Nelson - Director, Quality Assurance and Risk Management APA Barlow verified with Knepler information received by CCL from the media as follows: • $25M lawsuit against the community located in Bakersfield • Photography lawsuit against one of the properties • lawsuit against a Skilled Nursing Facility (SNF) in the Healdsburg location Knepler states that despite the lawsuits, there is no financial impact to any of the properties, residents or staff of the company. Knepler added there are no vendor issues as well. continuation on LIC 809C Knepler also states that management communicates with the staff and residents to make them aware of the changes. Signages have been changed. Knepler added that the bankruptcy did not affect any of the communities because Pacifica Senior Living Management was no longer the management company for any of the Pacifica Communities, that the communities had given notice to the department and residents back in October or November of last year of the changes in management companies. He said that the judgment in Bakersfield did not involve the operating entity, only the management company. He said there were no other suits pending against any of the Pacifica entities. APA requested the following documents be provided to CCL by today: • Spread sheet of all facilities whose management company was/is Pacifica Senior Living Management Company • management companies for each location • letter provided to the residents notifying them of the changes At the conclusion of the meeting, APA emphasized to Knepler the importance of communicating with CCL any lawsuits that the company may have in the future. Knepler agreed with APA. A copy of this report was provided to Knepler. ***Original signature is on file with the Pacifica Senior Living Union City facility.the state’s words, verbatim · CDSS document, Apr 4, 2025

Type of visit: Case Management - Incident

02/03/2025 10:00 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with Executive Director Irene Davis. Today’s visit is regarding an incident that was reported to licensing on 01/20/2025 regarding an incident that occurred on 01/11/2025. It was reported that Staff 1 (S1) was doing status check rounds on the residents and didn't see Resident 1 (R1). S1 then searched all rooms in the memory care unit. When S1 couldn't find R1 she notified the resident services director (RSD). RSD implemented the elopement protocol to search the facility, getting all staff engaged. It was reported that no elopement alarms were heard. Staff were sent to each hall - every exit and front and back grounds. Staff announced over the walkie, they found R1 and escorted R1 back to the memory care unit. R1 had walked outside using the exit by unit 237 laundry room. Resident 2 (R2) was outside walking their dog and saw R1 exit 237 back door. R2 escorted R1 back into the community and was walking her down the hall to R1's apartment. Staff 2 (S2) saw R1 walking with R2 and escorted R1 back to the memory care unit without incident. During the investigation it was learned that R1 had walked out of the memory care unit, possibly exited with visitors. R1 walked down the hall to the stairway and was exiting the building when they were escorted back inside by another resident. R1 had been outside of the memory care unit for a total of 10 minutes. In order to prevent this from happening again the facility conducted an elopement drill, increased staff checks for R1. The facility is trying to keep R1 more engaged in activities and has offered to take R1 on shopping trips but R1 has refused. The facility has notified visiting families to be cautious when exiting the memory care unit to ensure that residents do not walk out with them. No deficiencies were cited as a result of today’s visit. Exit interview conducted and a copy of the report was provided to with Executive Director Irene Davis.the state’s words, verbatim · CDSS document, Feb 4, 2025

Type of visit: Case Management - Other

11/14/2024 02:30 PM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility and met with Administrator Irene Davis. The purpose of the visit was to conduct an unannounced case management visit to deliver and confirm orders to individual for immediate exclusion from all facilities. LPA Knight served order of immediate exclusion effective 11/14/2024 and explained the "Immediate Exclusion" notice indicating that Staff 1 (S1) cannot be allowed to work, be present, and/or live in a CCL licensed facility, or have contact with clients in any residential facility or child day care licensed by the California Department of Social Services. Therefore, the Department orders the facility to remove S1 from any contact with residents and not allow S1 to be physically present in the facility. Administrator indicated they understood the notice and confirmed that S1 is currently not working at the facility. Exit interview completed. Copy of report was provided to Executive Director Irene Davis. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Nov 14, 2024

Type of visit: Case Management - Other

11/14/2024 03:45 PM Licensing Program Analyst (LPA) Rebecca Knight conducted an unannounced case management visit and met with Executive Director Irene Davis. Today’s visit is regarding an incident that was reported to licensing on 10/09/2024. On 10/092024, the regional office received an incident report regarding a report of financial abuse from a staff to a resident. During the course of the investigation, it was learned that Staff 1 (S1) was not associated to the facility. On 10/08/2024 the CCLD Duty Officer pulled a Guardian Person Summary for Staff 1 (S1). This report revealed that S1 has been associated to four facilities, Country Crest Assisted Living is not on the list of facilities S1 has ever been associated to. On the same day, the duty officer pulled a Guardian Personnel list for Country Crest Assisted Living and S1 was not on that list. Therefore, S1 has never been associated to the facility and was working in the facility while not associated to the facility. A civil penalty was assessed in the amount of $500.00 on 11/14/2024 on the attached LIC421. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the allegation that staff was working in the facility without being associated to the facility is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC809D. Appeal rights were provided. Exit interview was conducted and the report was provided to administrator Irene Davis.the state’s words, verbatim · CDSS document, Nov 14, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(c) · Plan of correction due date: Nov 28, 2024

87355(c) Criminal Record Clearance (c) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from Trust Line to a state licensed facility. This requirement is not met as evidenced by: Based on file review the licensee did not comply with the section cited above as S1 was working in but was not associated to the facility which poses an immediate health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 14, 2024

Plan of correction: Licensee is to submit in writing the date and details of S1 being terminated from employment. Additionally, the licensee shall review this regulation and submit a statement of understanding of the regulation. Both of these requirements are to be submitted to LPA by 11/28/2024. A civil penalty in the amount of $500.00 is being issued on 11/14/2024

Type of visit: Case Management - Deficiencies

10/17/2024 10:00 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with Executive Director Irene Davis. Today’s visit is regarding an incident that was reported to licensing on 10/09/2024. On 10/092024, the regional office received an incident report regarding a report of financial abuse from a staff to a resident. The local police department had contacted the facility attempting to locate Staff 1 (S1) because she had cashed a check for $2500.00 that belongs to Resident 1 (R1). The resident (no dementia diagnosis) stated they had not given S1 a check and the police have determined that the check was not written by R1. R1 states they are missing two check books. The facility has secured all of R1's checks. R1 states that on 10/07/2024 S1 called them twice and hung up. S1 no longer has access to the residents, was placed on administrative leave immediately, and was terminated from employment on 10/09/2024 as a result of the incident. As a result of the investigation, it was determined that Staff 1 (S1) stole a check from S1’s room, forged and cashed the check and withdrew funds from R1’s checking account which constitutes financial abuse of the resident. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the allegation that staff financially abused a resident is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC809D. Appeal rights were provided. Exit interview was conducted and the report was provided to administrator Irene Davis.the state’s words, verbatim · CDSS document, Oct 17, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Oct 31, 2024

87468.2(a)(8) Additional Personal Rights of Residents in Privately Operated Facilities (a)(8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement is not met as evidenced by: Based on document review and interviews the licensee did not protect R1 from being financially abused by S1 resulting in significant financial loss to R1. This poses an immediate Health, Safety and Personal Rights risk to clients in care.the state’s words, verbatim · CDSS document, Oct 17, 2024

Plan of correction: Licensee agrees to conduct staff training for all current staff regarding the penalties for perpetrating financial abuse of a resident and the consequences and penalties they will face if they do so. Additionally licensee agrees to hold staff training regarding accepting gratuities and gifts from residents and consequences of doing so. Licensee shall submit staff training sign in sheet as proof of correction.

Type of visit: Required - 1 Year

06/03/2024 10:00 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with administrator Irene Davis and explained the purpose of the visit. LPA Knight and the administrator toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to assisted living and memory care sections of the facility including resident rooms, common areas, activity room, laundry room, bathrooms, kitchen, storage areas. Staff and resident files were reviewed. All employees requiring background checks are cleared. Medications were reviewed. Medication is locked in locked med room. There is a schedule of recreational activities planned for the residents. Bedding, linens, and towels for residents were observed and found to be clean and in good repair. The facility was observed to be at a comfortable temperature. Common area was clean and in good repair. All bedrooms had required furniture, bedding, and lighting. Kitchen was clean and in good repair. Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. Fire extinguishers fully charged and were inspected in December 2023. Johnson Control comes in quarterly to inspect the fire alarm, sprinklers and smoke detector systems. They also come in annually to inspect the ansul system in the kitchen. There are no pools/bodies of water are on premises. Last disaster drill was conducted in February 2024, which was an active shooter drill, the facility has been conducting fire drills every 2 months. Continued on LIC809-C LPA requested the following documents that need to be updated in the facility file: LIC500 Personnel report Deficiencies are being cited as a result of today's inspection and is included on the attached LIC809-D. LPA inspected 10 resident rooms and observed that 1 of 10 bathroom fans was non-operational. LPA observed that lightbulbs in 3 of 10 resident bathrooms were either missing or non-operational. LPA reviewed staff files and 4 of 4 staff files that were reviewed did not have current first aid certificates on file. Exit interview conducted and copy of report was provided to administrator Irene Davis.the state’s words, verbatim · CDSS document, Jun 3, 2024

Type of visit: Case Management - Incident

12/06/2023 12:45 PM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with Executive Director Irene Davis. Today’s visit is regarding an incident that was reported to licensing via death report. LPA made the visit to attain additional detail related to the incident and gain insight into the sequence of events. The death report stated that Resident 1 (R1) was sent to skilled nursing after a hospital stay at Oroville Hospital due to a fall with head trauma and possible syncope. R1 was in the process of being admitted to hospice on the date of their expiration with intent to return to Pacifica Legacies Community. On 11/13/2023 R1 was found without a pulse and not breathing. R1 was DNR and was allowed a natural death at the skilled nursing facility. During the course of the investigation, it was learned that R1 had moved into the facility on 10/04/2023. On 10/09/23 care staff found R1 in the entry way of the memory care unit, staff noted a skin tear on R1’s left upper arm, staff also noticed some edema on R1’s right heal. 911 was called and R1 was transported to Oroville Hospital to be examined and treated. R1 returned to the facility the same day with diagnosis of left heel pressure blister, was sent home with antibiotics. On 10/10/23 staff found R1 on the floor in the dining room, bleeding from a cut above their right eye due to an unwitnessed fall. R1 had a dementia diagnosis and they had spontaneously tried to get up out of their wheelchair, even though they could not hold their own weight unless being transferred. R1 had lost the ability to maintain the sequence of standing and walking. R1 was sitting in the common area watching Tv with the other residents. Staff walked away for a minute around the corner and came back and R1 was on the floor. 911 was called and transported R1 to Oroville Hospital to be evaluated. R1 was treated for the head wound receiving stitches to the laceration and IV antibiotics for the ulcer on their heal. R1 was kept in hospital for observation and for IV antibiotic treatment for edema. Resident tested positive for Covid 19 while at Oroville Hospital during their stay. R1 was sent to skilled nursing for physical therapy due to falls. R1 was at the skilled nursing facility for 3 to 4 weeks and passed away at the skilled nursing facility on 11/13/2023. No deficiencies were cited as a result of today's visit.the state’s words, verbatim · CDSS document, Dec 6, 2023

Allegation investigated: Staff are not following proper infection control requirements - UNSUBSTANTIATED Staff left residents unattended - UNSUBSTANTIATED Facility does not have sufficient emergency food supplies - UNSUBSTANTIATED

/01/2023 1:25 PM Licensing Program Analyst (LPA) Rebecca Knight made an unannounced visit to the facility and met with administrator Irene Davis. The purpose of this visit was to deliver the results of a complaint investigation. During the course of the investigation the Executive Director and 1 staff were interviewed. The following documents were received and reviewed: staff list with telephone numbers, staff schedules for September 2023 for kitchen staff and memory care staff. Continued on LIC9099-C Unsubstantiated Staff are not following proper infection control requirements- UNSUBSTANTIATED It was reported that kitchen staff do not use hair nets and do not wash their hands. During an unannounced visit to the facility on 10/06/2023 LPA entered the vestibule that leads to the kitchen doors. LPA observed a sign on the door that reads "All employees must wash hands and wear a hair net. When entering the vestibule LPA observed a kitchen staff enter the kitchen, apply a hairnet and wash their hands, this staff person was unaware of LPA’s presence during this observation. LPA observed four staff working in the kitchen, all wearing hair nets. Executive Director stated that California Department of Public Health received the same complaint because the facility prepares meals for their skilled nursing facility. CDPH investigated the same allegations. The only citation they issued was for a mislabeled box, no other citations were issued. This allegation is unsubstantiated. Staff left residents unattended- UNSUBSTANTIATED It was reported that there was a shortage of kitchen staff and memory care staff were assisting in the kitchen leaving the memory care unit unattended. LPA reviewed the kitchen staffing schedule for the month of September 2023. On 9/24/2023 the schedule shows that one cook called out for the day and tended their resignation over the phone. On the same day a second cook walked out of the building at 7:30 AM without notice. The Dietary Services Manager came on shift after being notified. The Executive Director provided additional assistance. LPA reviewed the memory care staffing schedule for the month of September 2023. On 9/24/3023 the schedule shows there was 1 med tech and 2 care staff on duty for the shift of 6:30 AM through 2:30 PM. Continued on LIC9099-C Page 2 Executive Director stated the med techs were in the kitchen for approximately ½ hour the day the cook walked out. During this time there were 2 care staff in Memory Care. 1 care staff, 1 server and 1 med tech were in the kitchen. The med tech that was in the kitchen was readily available for meds and emergencies during that time. The Dietary Services Director was already on their way and arrived approximately 30 minutes after the cook left. It was determined that there were two care staff in the Memory Care unit while the med techs were assisting for 30 minutes in the kitchen due to the short-term staffing shortage. This allegation is unsubstantiated. Facility does not have sufficient emergency food supplies - UNSUBSTANTIATED During an unannounced visit to the facility on 10/06/2023 LPA observed an ample supply of non-perishable foods in the kitchen pantry. This allegation is unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED. An exit interview was conducted. A copy of the report was provided to administrator Irene Davis.the state’s words, verbatim · CDSS document, Nov 1, 2023 · control 59-AS-20230929132623

Type of visit: Case Management - Incident

09/28/2023 12:35 M Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with Administrator Irene Davis. Today’s visit is regarding an incident that occurred on 09/16/2023 and was reported to licensing on 09/23/2023. It was reported that on 09/16/2023 at 7:10 PM Care staff was transferring Memory Care Resident 1 (R1) to the toilet and R1 slipped and fell on their bottom. Staff assessed R1 for injuries, none were noted but R1 complained of hip pain. The Med Tech called EMS and R1 was transported to a local hospital for evaluation and treatment. R1’s POA was notified. R1 was admitted to the local hospital to be treated for a compression fracture to their right hip. R1 will not be returning to the facility and will be admitted to skilled nursing as R1 is not cognitively aware enough to care for their hip and prevent further complications. LPA interviewed administrator and Memory Care Director during the visit. LPA obtained documents during the visit. LPA will conduct telephone interview with staff and return for a follow up visit. No deficiencies were cited as a result of today’s visit.the state’s words, verbatim · CDSS document, Sep 28, 2023