Ivy Park at Milpitas

Type of visit: Case Management - Incident

On September 18, 2026, Licensing Program Analyst (LPA) Manuel Monter conducted a follow up unannounced case management - incident visit regarding an incident wherein resident R1 eloped from the facility. LPA met with Regional Health Services Specialist Sharisse Toves and explained the purpose of the visit. On September 11, 2026, Licensing Program Analyst Manuel Monter was informed via email from Administrator Meghian Geul, stating resident R1 eloped from the memory care unit, on September 11, 2026. R1 had climbed over the fence in the memory care unit and left the community around 8:32am, Staff reported R1 missing at 9am. R1 was found at his/her family member's house at 2:30pm. R1 had walked into his/her house, and R1's family member (FM) called the facility inform them he/she was there. R1 was assessed by staff at the FM's house, and had the ambulance take him/her to Santa Clara Kaiser to be evaluated. LPA interviewed Facility staff. At this time, this case in under review and the Department will conduct a follow visit , if warranted. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Regional Health Services Specialist Sharisse Toves and a copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 18, 2026

Type of visit: Case Management - Incident

On September 16, 2026, Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced case management - incident visit regarding an incident report regarding resident R1. LPA met with Regional Health Services Specialist Sharisse Toves and explained the purpose of the visit. On August 19, 2026, Licensing Program Analyst Manuel Monter was informed by staff S1 that resident R1 had eloped from the facility on August 18, 2026 at around 10:10pm. S1 stated R1 became upset after he/she had not invited to a familial event. S1 stated R2 initially believed that R1 was still at the facility gym at that time around 10:00pm. S1 stated R1’s son/daughter went downstairs to walk a dog and believed he/she saw R1 exit through the front door. S1 stated he/she became aware around 10:10 PM that R1 eloped. S1 stated when he/she was informed that R1 had eloped, staff were looking all over the entire facility. S1 stated when they couldn’t find R1, they contacted 911 around 10:50pm. S1 stated at the same time, it was reported that someone matching R1’s description was found by the great mall. S1 stated R1 was brought back to the facility around 11:00pm. No injuries noted on R1. S1 stated R1’s partner, R2, went on vacation about 3 weeks ago. S1 stated when R2 was on vacation, S1 observed R1 showing signs of confusion. S1 stated on one occasion, he/she observed R1 sitting on a bench near the dinning room elevator. S1 stated he/she asked R1 what he/she was doing. R1 responded he/she didn’t know where he/she was and was lost. S1 acknowledged that he/she should have given R1 a re-assessment, after viewing these behaviors. S1 stated R1 was allowed to leave the facility unassisted based on the physician’s report. LPA reviewed R1’s physician’s report, which indicated R1 cannot leave the facility unassisted. LPA showed S1 and S1 stated the facility must have misread it. Page 1 Out of 4. On August 19, 2026, Licensing Program Analyst Manuel Monter interviewed staff S2-S4. S2 stated he/she is familiar with R1 and described him/her as mostly independent. S2 stated R1 has a neurocognitive disorder. S2 stated she usually sees R1 two to three times per day when he/she is on shift. S2 stated he/she has not observed any changes in R1’s behavior. S3 stated R1 is independent. S3 stated he/she sees R1 2x per week. S3 stated he/she has not observed any changes in behaviors regarding R1. S4 stated R1 has a neurocognitive disorder and typically keeps to him/herself and R2. S4 stated he/she has not observed any concerning behaviors from R1 and stated that, as far as he/she had seen, R1 did not demonstrate behavioral issues. S4 stated on August 18, 2026, at around 10:15 PM, S1 informed him/her that R1 had eloped. S4 stated R1’s son/daughter was present and explained what had occurred. S4 stated he/she, S1, and family members searched the entire building and surrounding area. S4 stated R1 was located at approximately 11:00 PM by local law enforcement, following reports of an individual near the Great Mall area. S4 stated R1 was transported back to the facility, where he/she observed him/her and did not note any injuries. On August 19, 2026, Licensing Program Analyst Manuel Monter interviewed residents R1 and R2. LPA asked R1 what occurred on August 18, 2026. R1 stated he/she doesn’t recall what happened yesterday. R1 stated he/she only recalls that he/she went for a walk that lasted 45 minutes. R1 stated he/she doesn’t actually know what time he/she left the facility. R1 stated he/she does remember that he/she was lost yesterday and it was dark. R1 stated because it was dark, he/she had difficulty finding his/her way back. R1 stated he/she doesn’t remember interacting with the police. R2 stated his/her son/daughter was present at the time of the elopement. R2 stated he/she and his/her son/daughter were watching a television show (“Ted Lasso”), and R1 became tired of waiting and told them he/she was going out for a walk. R2 stated R1 sometimes goes downstairs to the gym to use the elliptical machine, and he/she did not check to confirm where he/she went. R2 stated R1 left the building. R2 stated R1 was fine when he/she returned to the facility and that he/she told R1 that he/she could not leave the facility unassisted. Page 2 Out of 4. On August 24, 2026, the Department received an Incident Report (IR) regarding resident R1. The IR stated on August 18, 2026, at 10:10pm, assisted living resident with neurocognitive disorder, walked out of the front door without his/her watch or cell phone. At 10:10pm it was reported that R1 wasn't found. At 10:50pm, 911 was called. Coincidentally a report was made to police that someone fitting the description appeared confused and lost at the Great Mall. Police approached R1 and was brought back by police officers at 11:10pm. On August 26, 2026, Licensing Program Analyst Manuel Monter interviewed staff S5-S15. 4 out of 11 staff (S5, S6, S7, S12 ) stated they are not aware of R1’s behaviors or anything of note regarding R1. 5 Out of 11 staff (S8, S9, S10, S11, S15) stated they have not had any interactions with R1. S13 stated during his/her shift, he/she administers medication to R1. S13 stated when he/she is administering medications, he/she has noted R1 will forget that he/she is supposed to take the medication. S13 stated when he/she knocks R1’s apartment door to give R1 his/her medication, he/she can hear R2 tell R1 to open the door. S13 stated after R1 opens the door, he/she will go into the apartment, towards the bedroom. S13 stated R2 will remind R1 that he/she needs to go back and meet with S13, because he/she is there to administer his/her medications. S13 stated he/she has given R1 his/her medications, and R1 will not take the medication until he/she has been prompted to take the medication. S13 stated R1 will be given medication on hand and a glass of water. S13 stated he/she has to tell R1 every step to take the medication. S13 clarified that sometimes R1 does sometime know what to do. S13 also noted during that time R2 was not at the facility, he/she has observed R1 in the hallway lost. S13 stated he/she observed R1 on the second floor seated on one of the seats. S13 stated she asked R1 what he was doing. R1 stated he didn’t know. S13 stated he/she assisted R1 back to his/her bedroom. S14 stated R1 is very forgetful. S14 stated R1 has come to his/her work area asking for things, as if they were a store, appearing confused. S14 stated he/she does remember times when R1 has asked him/her for directions- like where the dinning hall is or the elevators are. S14 stated R1 was being serious and appeared confused and was not joking. S14 stated he/she couldn’t note any specifics regarding dates when these events took place. Page 3 Out ot 4. The Department reviewed R1’s Physician’s Report, dated April 27, 2026 states R1 has major Neurocognitive disorder. Page 6 states R1 would be at risk if allowed to leave the community unsupervised due to neurocognitive disorder. The Department Reviewed Resident R1’s Needs and Services Plan, dated May 30, 2026, states R1 is able to leave community independently. The Department Reviewed R1’s Progress Notes, dated August 18, 2026. The note states R1, with neurocognitive disorder, walked out of the front door without his/her watch or cell phone. R2 assumed R1 would go to the gym but when he/she went to the gym, R1 wasn’t there. R2 couldn’t find R1. R1’s son/daughter assisted in searching and called staff to report at 10:10pm. Staff searched the building and the surrounding area. At 10:50pm, 911 was called and coincidently a report was made that someone fitting the description appeared confused and lost at the great mall. Local Law enforcement brought back R1 back to the facility at 11:10pm. Based on a search on google maps, the location between Ivy Park Milpitas and the Great Mall is approximately 0.8 miles. On August 26, 2026, a case management was conducted and the facility was cited a Type A deficiency under the code section, 87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)(4). The facility was also issued an immediate civil penalty of $500 for absence of supervision, for an elopement that occurred on August 6, 2026. On July 20, 2026, a case management was conducted and the facility was cited a Type B deficiency under the code section, 87463 Reappraisals (a). As a result, the Department issued an immediate civil penalty of $1,000 for a repeat violation the absence of supervision, which resulted in R1 eloping from the facility. The Department will also issue an immediate civil penalty of $250 for a repeat violation, under code section 87463 Reappraisals (a). Deficiency cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D. This report was reviewed with Regional Health Services Specialist Sharisse Toves and a copy of the report was provided. Appeal Rights was provided. Page 4 Out of 4.the state’s words, verbatim · CDSS document, Sep 16, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Sep 17, 2026

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)(4) To care, supervision, and services …to meet their needs. This requirement was not met as evidence by: Based on interviews & records reviewed, on August 18, 2026, resident R1 eloped from the facility unassisted. R1’s physician’s report dated 4/27/2026 states R1 has a neurocognitive disorder and cannot leave the facility unassisted. R1 was found by law enforcement 0.8 miles away from the facility.the state’s words, verbatim · CDSS document, Sep 16, 2026

Plan of correction: ADM stated that she will provide a written plan of action outlining how she will ensure that residents residing in the assisted living side of the facility, who cannot leave the facility unassisted, have their supervision needs are being met. ADM stated she will submit the plan of action to LPA by POC due date September 17, 2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87463(a) · Plan of correction due date: Sep 23, 2026

87463 Reappraisals (a) The pre-admission appraisal…shall be updated in writing as frequently as necessary … to note significant changes in condition… and to keep the appraisal accurate. …shall be referred to as the reappraisal. This requirement is not met as evidenced by: Based on record review, R1’s care plan dated May 30, 2026, did not address the fact that R1 could not leave the facility unassisted, as per R1’s Physician’s Report dated April 27, 2026. S1 indicated that he/she had observed R1 exhibiting signs of confusion and appearing lost.the state’s words, verbatim · CDSS document, Sep 16, 2026

Plan of correction: ADM stated she will submit a written plan of action on how she will ensure residents care plans are updated in writing as frequently as necessary to note significant changes, and to keep the appraisal accurate. ADM stated she will submit the plan of action to LPA by POC due date September 23, 2026. S1 stated he/she should have given R1 a re-assessment, after viewing these behaviors. S1 acknowledged it was a mistake on his/her part. This poses/posed a potential health, safety or personal rights risk to persons in care.

Type of visit: Case Management - Incident

On September 14, 2026, Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced case management - incident visit regarding an incident wherein resident R1 eloped from the facility. LPA met with Regional Health Services Specialist Sharisse Toves and explained the purpose of the visit. On September 11, 2026, Licensing Program Analyst Manuel Monter was informed via email from Administrator Meghian Geul, stating resident R1 eloped from the memory care unit, on September 11, 2026. R1 had climbed over the fence in the memory care unit and left the community around 8:32am, Staff reported R1 missing at 9am. R1 was found at his/her family member's house at 2:30pm. R1 had walked into his/her house, and R1's family member (FM) called the facility inform them he/she was there. R1 was assessed by staff at the FM's house, and had the ambulance take him/her to Santa Clara Kaiser to be evaluated. LPA requested copy's of R1's documents. At this time, this case in under review and the Department will conduct a follow visit , if warranted. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Regional Health Services Specialist Sharisse Toves and a copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 14, 2026

Type of visit: POC

Licensing Program Analyst Manuel Monter conducted a POC case management visit to clear deficiencies cited on August 26, 2026, regarding the conclusion of a case management - incident and to amend a Complaint investigation (26-AS-20260421104409), LIC9099, LIC9099-C issued on August 6, 2026. LPA met with Administrator Meghian Geul. and explained the purpose of the visit. The complaint investigation closed on August 6, 2026 is being amended and re-opened due to new information provided to the Department. The facility was cited the following Type A deficiency on August 26, 2026 87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)(4), POC due date August 27, 2026 LPA received plan of corrections for type A deficiency by POC due date. Deficiencies cleared during todays visit. POC cleared letter provided to ADM No deficiency was cited during todays visit. This report was reviewed with Administrator Meghian Geul. A copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 3, 2026

Allegation investigated: Staff are mismanaging resident's medication

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced complaint inspection to deliver the findings on the above allegation. LPA met with Administrator Meghian Geul On July 30, 2026, the Department received a complaint alleging Staff are mismanaging resident 's medication. Its been alleged the facility received 30 medication tablets of medication M1 on July 7, 2026, and the facility had ran out of Medication M1 on July 26, 2026. On July 31, 2026, Licensing Program Analyst Manuel Monter interviewed Resident Care Coordinator, Shristi Pasad, referred to as RCC. RCC described the facility’s protocol for receiving medications. RCC stated that when medications arrive, staff centrally log them, check that the medications are correct, by cross referencing the doctors orders and ensuring they are the correct medication for the correct resident, and endorse the information to the next shift. Page 1 Out of 4. Unsubstantiated RCC stated staff count the medications, confirm the order is present, and verify that the order matches the medication received. RCC stated that if the medications received differ from the order, the facility has 48 hours to have the pharmacy correct the issue. On August 6, 2026, Licensing Program Analyst Manuel Monter interviewed Administrator Meghian Geul. ADM stated it’s the facility’s policy when receiving medications, that the medtech or other qualified staff member, needs to log said medication on the Centrally stored medication record check that the medications are correct, by cross referencing the doctors orders. ADM stated that staff member also needs to count the medication and verify that the order matches the medication received. ADM stated if a discrepancy is noted, they need to notify their supervisor. On August 6, 2026, Licensing Program Analyst Manuel Monter interviewed Health Services Director Cathy Lourdes Platon, referred to as HSD. HSD stated the facility policy regarding receiving medications is as follows. HSD stated staff are supposed to read over the medication order. If it’s a narcotic, they count how many medications tablets it contains. HSD stated then its entered on the narcotics log and the Centrally stored medication record. LPA asked HSD that if the facility receives a medication from the pharmacy and it is observed that the number of medication tablets inside the container does not match the tablet count indicated on the medication label, what steps staff are supposed to take in that situation. HSD stated staff are supposed to report it to the supervisor or to HSD if there is a discrepancy in the count. HSD stated this discrepancy, for resident R1's M1 was not reported to her. HSD stated they only found out about this discrepancy on July 24th when it was observed there was only 2 medication tablets left. HSD stated when it was discovered, they immediately tried to refill, but the pharmacy had stated it was too early and that they had delivered 30 tablets. HSD stated they also contacted the doctors office as well, but the doctor didn’t initially approve the replacement for 10 tablets. HSD stated she got in contact again with resident R1’s Doctor on July 27, 2026, and informed them that 10 additional tablets were needed. HSD stated they R1’s medication M1 arrived Friday July 31, 2026. Page 2 Out of 4. On August 11, 2026, Licensing Program Analyst Manuel Monter interviewed Witness W1. W1 stated on July 7, 2026, the pharmacy filled 30 tablets of medication M1. W1 stated on July 23, 2026, the facility called the pharmacy stating they only received 20 tablets and they needed an additional 10 tablets. W1 stated the facility still had several medication tablets to administer at the time of the call. W1 stated the facility got a new prescription for the additional 10 medication tablets on July 28, 2026. The Department reviewed R1’s Centrally Stored Medication Record (CSMR). The CSMR indicates that Medication M1, with a fill date of July 6, 2026, also has a strength of 0.25 mg and contains 20 tablets. The instructions for this supply state: take 1 tablet and allow it to dissolve every night at bedtime. The Department Reviewed FAX Communication regarding R1’s Medication Orders. The fax communication states, Medication M1’s order was last written on June 15 , 2026. With 2 refills noted, and 30 tablets. The Department reviewed Resident R1’s Controlled Drug Administration Record, which states the amount of tablets received for Medication M1, is 20 tablets on July 7, 2026. The Department Reviewed Resident R1’s medication M1 label, which has a fill date of July 6, 2026 and a tablet count of 30. The Department reviewed an email communication from Health Services Director Cathy Platon date July 27, 2026, which stated the following, "During preparation for resident R1's M1’s refill, we identified a discrepancy between the quantity documented as received and the quantity dispensed by the pharmacy. The pharmacy label indicates that 30 tablets were dispensed; however, the initial narcotic inventory entry reflects receipt of 20 tablets. This discrepancy was not identified at the time the medication was received and was only discovered when the current supply was exhausted and a refill was needed. The R1's last available dose was administered yesterday. Upon discovering the discrepancy, we contacted the Pharmacy and the prescribing provider to request an interim supply of 10 tablets" Page 3 Out of 4. Based on investigation and interviews conducted, resident R1’s medication M1 was noted to contain 20 tablets, which conflicted with what the medication M1’s label noted, which was 30 tablets. RCC, HSD and ADM stated its Ivy Park Milpitas protocol when medications arrive, that staff is supposed to log the medications on the Centrally Stored Log, count the medications and ensure it matches with the doctors order. RCC, HSD and ADM stated discrepancies must be brought to the attention of the supervisor or HSD. Although it is a fact that the facility staff did not respond to the discrepancy noted in a timely manner, the facility’s program does not explicitly state that the facility will count medication tablets when a new medication is received. Furthermore, under title 22, there is no specific regulation that requires the facility to count medication as it arrives. Based on investigation, once the discrepancy was noted, HSD contacted R1’s Doctor and Pharmacy on July 24, 2026. Therefore, 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 allegations did or did not occur. Exit interview was conducted with Administrator, Meghian Geul and a copy of the report was provided. Page 4 Out of 4. End of Report.the state’s words, verbatim · CDSS document, Aug 26, 2026 · control 26-AS-20260730160400

Type of visit: Case Management - Incident

On August 26, 2026, Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced case management - incident visit regarding an incident report regarding resident R1. LPA met with Administrator Meghian Geul and explained the purpose of the visit. On August 7, 2026, facility Administrator (ADM) Meghian Guel contacted the Department to report an incident regarding resident R1. ADM stated there was an elopement that occurred in the memory care unit (MCU) on August 6, 2026, at around 3:00pm. ADM stated when they discovered that R1 had eloped from the facility, they contacted local law enforcement for assistance. ADM stated resident R1 had was found a little before 4:00pm at the great mall by local law enforcement. ADM stated R1 was fine. No injuries noted. On August 12, 2026, Licensing Program Analyst Manuel Monter interviewed staff S2-S7. S2 stated on August 6, 2026, he/she saw R1 last in the common area/activity area at 2:45pm, after being given a snack. S2 stated 15 minutes later, he/she was informed by staff that they couldn’t find R1. S2 stated during their checks, he/she noticed the delayed egress door (with the service elevator inside-across from room 125), on the left side was closed, and working. S2 stated when he/she opened that door, he/she noticed that the door beyond that was opened. S2 stated he/she inspected the area but did not observe R1. S2 stated while they were still searching for R1, he/she was notified by the Health Services Director (HSD) that R1 was found by the police, by Dave and Busters parking lot at the mall. Based on a search on google maps, the location between Ivy Park Milpitas and the Great Mall is approximately 0.8 miles. Page 1 Out of 3. S3 stated he/she was on the left side (corridor with rooms 125-135) of the memory care unit collecting laundry baskets to do laundry. S3 stated he/she was then informed by the medtech that R1 was missing and he/she assisted in searching for R1. S6 stated he/she was the staff member who noticed that R1 was missing. S6 stated when he/she started his/her shift, he/she did a head count and confirmed everyone was in the memory care unit. S6 stated he/she did notice R1 was wandering. S6 stated around 2:45pm he/she was serving snacks to the residents. S6 stated sometime around 2:50pm-3:00pm, he/she heard the delayed egress alarm on the right side of the memory care unit (end of hallway- across from 102). S6 stated he/she responded to the delayed egress in less than 30 seconds. S6 stated he/she checked the area but did not see any resident. S6 stated he/she then did a head count once again, and couldn’t find R1. S6 stated he/she then informed the Medtech and the memory care director was notified. S7 stated after the group meeting (which was approximately 20 minutes between about 2:30 PM and 3:00 PM) in common area regarding the activity monitor (IN2L program). S7 stated he/she then heard a door alarm activate (right side of the memory care unit end of hallway across from 102) and subsequently heard someone turn the alarm off. S7 stated he/she did not think anything of the alarm being activated and silenced. Approximately five minutes later, staff realized R1 could not be located. S7 stated staff then searched all areas of the facility and, when unable to locate R1. 2 Out of 6 staff (S4, S5) stated they were not working the day R1 eloped from the facility. 2 Out of 6 staff (S2, S3) stated the day of the elopement, they didn’t hear the delayed egress alarm. 4 Out of 6 staff (S2, S4, S5, S7) stated when R1 moved in, he/she was exhibiting wandering / exit seeking behaviors. On August 12, 2026, Licensing Program Analyst Manuel Monter interviewed resident R1. LPA attempted to interview resident R1, but R1 would ramble about unrelated topics and would mumble when responding. LPA made multiple attempts to ask R1 questions, but R1 did not provide any relevant information regarding the day he eloped from the facility. On August 17, 2026, Licensing program Analyst Manuel Monter interviewed staff S1 and S8. S1 stated the day of the elopement, he/she was changing another resident at the time. S1 stated as he/she was changing this resident he/she heard the delayed egress alarm. Page 2 Out of 3. S1 stated as he/she was finishing up, a staff member entered the bedroom he/she was in and was informed that R1 was not found and had possibly eloped. S1 stated when he/she started his/her shift, he/she observed R1 moving around the memory care unit and going place to place trying to exit. S8 stated at the time he/she was passing out medications to residents. S8 stated sometime later that day, he/she was informed by staff S6, that R1 couldn’t be found around 2:45pm-2:50pm. S8 stated he/she did not hear the delayed egress alarm ring. S8 stated the the day of the elopement was the first time he/she met R1. S8 stated when he/she was introduced to R1, he/she did notice that R1 was being erratic and was constantly exit seeking. The Department reviewed R1’s Progress notes. Progress note dated August 5, 2026- R1 was wandering around the community trying to find an exit. Progress note dated August 6, 2026 states, (am) R1 still acclimating to community. R1 spend most of the shift wandering throughout the Memory Care, while attempting to find an exit. R1 was difficult to redirect and requires close monitoring due to fall and elopement risk. R1 received snack around 2:45pm from care giver. R1 continued ambulating with walker around the community. At 3:00pm care giver could not find R1. Elopement protocol initiated. Police informed. R1 was found at the great mall. The Department reviewed R1’s Service Plan dated August 7, 2026. The Service Plan states R1 has severe impairment and demonstrates poor judgement and is potentially disruptive and dangerous to self and others. The Department reviewed R1’s Physician’s Report, dated August 2, 2026. The physician report states R1 has a neurocognitive disorder and cannot leave the facility unassisted. R1 also lacks hazard awareness. As a result, the Department issued an immediate civil penalty of $500 for absence of supervision, which resulted in R1 eloping from the facility. Deficiency cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D. This report was reviewed with Administrator Administrator Meghian Geul and a copy of the report was provided. Appeal Rights was provided. Page 3 Out of 3. End of Report.the state’s words, verbatim · CDSS document, Aug 26, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Aug 27, 2026

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)(4) To care, supervision, and services …to meet their needs. This requirement was not met as evidence by: Based on interviews and records reviewed, on August 06, 2026, resident R1 with a neurocognitive disorder eloped from memory care unit unassisted and was found by law enforcement 0.8 miles away from the facility.the state’s words, verbatim · CDSS document, Aug 26, 2026

Plan of correction: ADM stated R1 has a 1 on 1 care giver and now has a wander guard as well. ADM stated the facility conducted Elopement training for all shifts. ADM stated she will send LPA a copy of recent training. ADM stated she will submit plan on how she will ensure an elopement doesn't occur again . This poses an immediate Health, Safety, or Personal Rights risk to persons in care.

Type of visit: Case Management - Incident

On August 19, 2026, Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced case management - incident visit regarding an incident report regarding resident R1. LPA met with Administrator Meghian Geul and explained the purpose of the visit. On August 19, 2026, Licensing Program Analyst Manuel Monter was informed by the Health Services Director that a resident, referred to as R1 had eloped from the facility on August 18, 2026 at approximately 10pm. LPA interviewed health services director, staff and residents. At this time, this case in under review and the Department will conduct a follow visit , if warranted. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Administrator Meghian Geul and a copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 19, 2026

Allegation investigated: Staff do not ensure residents' needs are being met due to lack of staff. Staff does not ensure residents' showering needs are being met. Staff does not provide adequate meal service to residents. Staff does not ensure residents' laundry services are being met in a timely manner.

Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegations. LPA met with Health Services Director Cathy Lourdes Platon On April 07, 2026, the Department received a complaint alleging Staff does not ensure residents' laundry services are being met in a timely manner. On April 10, 2026, Licensing Program Analyst Steve Chang residents R1-R5. 4 Out of 5 residents (R1, R2, R4 R5) stated they received laundry services from staff, but did not provide additional information regarding the allegation due to neurocognitive disorder. R3 did not provide any relevant information regarding the allegation due to neurocognitive disorder. Page 1 Out of 7 Unsubstantiated On May 22, 2026, Licensing Program Analyst Manuel Monter and Steve Chang interviewed staff S1-S5. 3 Out of 5 staff (S2-S4) stated they are not aware of any issue or instance of neglect in regards to the facility not following the laundry schedule or doing the laundry for the residents in general. S1 stated there have also been instances, like 1-2 individual instances a month where facility staff are so busy, and they are not able to do all the residents scheduled laundry for that individual day. S1 stated this happens due to lack of staffing, instances where a staff call out. S5 stated he/she has observed residents’ laundry stacked up 5 days past the laundry scheduled date. S5 stated this happening to individual residents 1-2x a week. S5 stated the he/she has told the memory care director and the ADM, but it’s not being addressed. On May 22, 2026, Licensing Program Analyst Manuel Monter interviewed resident R6-R9. 4 out of 4 residents (R6-R9) stated they are not aware of any instance where a residents laundry needs were neglected. On May 22, 2026, Licensing Program Analyst Manuel Monter toured the following bedrooms with Administrator Meghian Geul. LPA toured the following but not limited to: 105 A+B, 104 A+B, 109, 110, 103 A+B, 111, 102 A+B, 101 A+B, 114, 100 A+B, 115 A+B, 125, 126, 127 A+B, 141, 128, 140, 129, 130, 139, 138 A+B, 137, 132, 133, 136A, 134 B, 135, 113, 272, 263. During the tour LPA did not observe any instance where a residents laundry needs were neglected. On June 16, 17, and July 23, 2026, Licensing Program Analyst Manuel Monter interviewed staff S6- S10. 5 out of 5 staff (S6-S10) stated they are not aware of any instance where a residents laundry needs were neglected. On July 23, 2026, Licensing Program Analyst Manuel Monter interviewed resident R10-R20. 11 Out of 11 residents (R10-R20) stated they have not had any issues with their laundry services or experienced any instances where their laundry needs were neglected. Page 2 Out of 7 Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegation as UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. Staff does not provide adequate meal service to residents. On April 07, 2026, the Department received a complaint alleging Staff does not provide adequate meal service to residents. On April 10, 2026, Licensing Program Analyst Steve Chang residents R1-R5. 2 Out of 5 residents (R1, R5) stated they received laundry services from staff but did not provide additional information regarding the allegation due to neurocognitive disorder. 3 Out of 5 residents (R2-R4) did not provide any relevant information regarding the allegation due to neurocognitive disorder. On May 22, 2026, Licensing Program Analyst Manuel Monter and Steve Chang interviewed staff S1-S5. Staff S2 and S4 stated they are not aware of any instances where residents did not receive their meals. Staff S1, S3, and S4 stated they are not aware of any time when residents breakfast was delayed until 10am. Staff S1 and S3 stated they heard about a resident not receiving their meal, but doesn’t know the details. S5 stated breakfast has been delayed, when served to the residents. S5 stated when they are short staffed, and only have 2 care givers and 1 medtech for over 30 residents, its not feasible to get every resident up, dressed and ready for breakfast by 8:00-8:30am. On May 22, 2026, Licensing Program Analyst Manuel Monter interviewed resident R6-R9. 4 out of 4 residents (R6-R9) stated they are not aware of any instance where a residents meal was not given and or is aware of any issues with the facility’s meal service. On June 16, 17, and July 23, 2026, Licensing Program Analyst Manuel Monter interviewed staff S6- S10. 5 out of 5 staff (S6-S10) stated they are not aware of any instances where residents did not receive their meals. Page 3 Out of 7 On July 23, 2026, Licensing Program Analyst Manuel Monter interviewed resident R10-R20. 9 Out of 11 residents (R10- R16, R19-R20) stated they are not aware of any instance where a residents meal was not given and or is aware of any issues with the facility’s meal service. R17 and R18 stated they have had issues with the meal deliver service, resulting in their meal being delayed. R17 and R18 stated they had made an order at 3:30pm, but it was not delivered until 6:15pm, after R18 went to the front desk to question the whereabouts of their meal. Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegation as UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. Staff does not ensure residents' showering needs are being met. On April 07, 2026, the Department received a complaint alleging Staff does not ensure residents' showering needs are being met. On April 10, 2026, Licensing Program Analyst Steve Chang residents R1-R5. 4 Out of 5 residents (R1, R2, R4 R5) stated they shower services from staff, but did not provide additional information regarding the allegation due to neurocognitive disorder. R3 did not provide any relevant information regarding the allegation due to neurocognitive disorder. On May 22, 2026, Licensing Program Analyst Manuel Monter and Steve Chang interviewed staff S1-S5. 3 Out of 5 staff, (S2 S4 S5) stated there hasn’t been a time when a resident was neglected their shower. 2 Out of 5 staff (S1, S3) stated there has been instances where a resident was scheduled to have a shower and wanted a shower, but was not given a shower, due to being short staffed. S3 stated this occurs at least once a month. Page 4 Out of 7 On May 22, 2026, Licensing Program Analyst Manuel Monter interviewed resident R6-R9. 4 out of 4 residents (R6-R9) stated they are not aware of any instance where a resident’s shower was neglected. On May 22, 2026, Licensing Program Analyst Manuel Monter toured the following bedrooms with Administrator Meghian Geul. LPA toured the following but not limited to: 105 A+B, 104 A+B, 109, 110, 103 A+B, 111, 102 A+B, 101 A+B, 114, 100 A+B, 115 A+B, 125, 126, 127 A+B, 141, 128, 140, 129, 130, 139, 138 A+B, 137, 132, 133, 136A, 134 B, 135, 113, 272, 263. During this tour, LPA did not observe any residents in a soiled or disheveled state. On June 16, 17, and July 23, 2026, Licensing Program Analyst Manuel Monter interviewed staff S6- S10. 5 out of 5 staff (S6-S10) stated there hasn’t been a time when a resident was neglected their shower. On July 23, 2026, Licensing Program Analyst Manuel Monter interviewed resident R10-R20. 4 Out of 11 residents (R11, R14, R16, R19) stated they are not aware of any instance where a resident’s shower was neglected. 7 Out of 11 residents (R10, R12, R13, R15, R17, R18, R20 ) stated they do not need assistance with showers. Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegation as UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. Staff do not ensure residents' needs are being met due to lack of staff. On April 07, 2026, the Department received a complaint alleging Staff do not ensure residents' needs are being met due to lack of staff. On April 10, 2026, Licensing Program Analyst Steve Chang residents R1-R5. 5 Out of 5 residents (R1-R5) did not provide any relevant information regarding the allegation due to neurocognitive disorder. On May 22, 2026, Licensing Program Analyst Manuel Monter and Steve Chang interviewed staff S1-S5. S4 stated there is enough staff to meet the needs of the residents. Page 5 Out of 7 S2 stated when the memory care unit is dealing with short staff, there might be some delay with care. S2 stated its hard to know when they will be short staff. S2 stated last minute call outs can make things difficult. S1 stated there have been instances where a resident was scheduled to have a shower and wanted a shower, but was not given a shower, due to lack of staffing. S1 stated there have also been instances, like 1-2 individual instances a month where facility staff are so busy, and they are not able to do all the residents scheduled laundry for that individual day. S1 stated this happens due to lack of staffing, instances where a staff call out. S3 stated there has been instances where a resident was scheduled to have a shower and wanted a shower, but was not given a shower that day. S3 stated this happens whenever they are short staffed. S5 stated regarding the staffing in the memory care unit: there is supposed to be 4 care givers and 1 medtech during Am and PM shift. S5 stated the issue is when there is unexpected call outs it and the facility isn’t able to add a new staff immediately, it leaves the other staff with the responsibility of the other staffs work / groupings. S5 stated whenever they are short staffed, it results in a delay in care. S5 stated he/she isn’t happy that they had a pregnant employee who wasn’t able to help out as much as possible. On May 22, 2026, Licensing Program Analyst Manuel Monter interviewed resident R6-R9. 3 out of 4 residents (R6, R8, R9) stated there is enough staff to meet the needs of the residents. R7 stated when all the staff go to work, then there is enough staff but if a staff member calls out sick, there is less staff, which causes a delay. R7 stated he/she is eventually assisted, but it takes longer. On May 22, 2026, Licensing Program Analyst Manuel Monter toured the following bedrooms with Administrator Meghian Geul. LPA toured the following but not limited to: 105 A+B, 104 A+B, 109, 110, 103 A+B, 111, 102 A+B, 101 A+B, 114, 100 A+B, 115 A+B, 125, 126, 127 A+B, 141, 128, 140, 129, 130, 139, 138 A+B, 137, 132, 133, 136A, 134 B, 135, 113, 272, 263. 38 Out of 39 bedrooms were observed as clean/orderly and in good repair. 1 Out of 39 bedrooms were observed requiring housekeeping which was addressed during the visit. Page 6 Out of 7 On June 16, 17, and July 23, 2026, Licensing Program Analyst Manuel Monter interviewed staff S6- S10. 4 out of 5 staff (S7 S8 S9-S10) stated there isn’t enough staff to meet the needs of residents in care. S9 stated there are 4 care givers during AM/PM shift and the facility has over 200 residents. S9 stated when they have call outs, it becomes difficult for the staff working to meet the needs of the residents. S10 stated staffing levels have decreased. S10 stated when he/she started, the assisted living side had 170 residents with 5 care givers in the AM/PM shift. S10 stated the assisted living AM/PM now operates with 4 care givers. 1 Out of 5 staff (S6) stated there is enough staff to meet the needs of the residents. On July 23, 2026, Licensing Program Analyst Manuel Monter interviewed resident R10-R20. 10 Out of 11 residents (R10-R15, R17-R20) stated there is enough staff to meet the needs of the residents. Resident R16 stated sometimes there isn’t enough staff to help residents and respond to pendants. R16 stated they need to hire more staff to meet the needs of the residents. On July 27, 2026, Licensing Program Analyst Manuel Monter interviewed Witness W1. W1 stated he/she has observed a pattern of staff calling out sick or being unable to report to work. W1 stated he/she observed on April 8, 2026 there were only 2 care givers on duty. W1 stated on April 20, 2026, he/she observed only 3 care givers working at the facility. LPA asked W1 how he/she determined there were only two or three staff present on the days he/she observed this. LPA also asked whether W1 knew if the other staff might have been assisting residents in their bedrooms with showers or changing. W1 stated that his/her observation was based on the number of staff he/she personally saw in the memory care unit and what staff had told him/her. W1 stated he/she has spoken to staff, who were upset due to under-staffing. W1 stated the staff have reported to him/her that the facility is short staffed. Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegation as UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. Page 7 Out of 7 End Of Report.the state’s words, verbatim · CDSS document, Aug 12, 2026 · control 26-AS-20260407085234

Type of visit: Case Management - Incident

On August 12, 2026, Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced case management - incident visit regarding an incident report regarding resident R1. LPA met with Health Services Director Cathy Lourdes Platon and explained the purpose of the visit. On August 7, 2026, facility Administrator (ADM) Meghian Guel contacted the Department to report an incident regarding resident R1. ADM stated there was an elopement that occurred in the memory care unit on August 6, 2026, at around 3:00pm. ADM stated when they discovered that R1 had eloped from the facility, they contacted local law enforcement for assistance. ADM stated resident R1 had was found a little before 4:00pm at the great mall by local law enforcement. ADM stated R1 was fine. No injuries noted. ADM stated R1 only appeared a little tired. ADM stated she doesn't believe that R1 had prior wandering or eloping behaviors. ADM stated all the delayed egress are working and they had tested them once R1 had returned. ADM stated the memory care director tested the delayed egress doors. On August 12, 2026, Licensing Program Analyst Manuel Monter toured the memory care unit inside and out with facility memory care director. LPA Manuel Monter interviewed staff and resident R1. At this time, this case in under review and the Department will conduct a follow visit , if warranted. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Health Services Director Cathy Lourdes Platon and a copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 12, 2026

Allegation investigated: Resident sustained multiple falls and bruises due to staff neglect

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced complaint inspection to deliver the findings on the above allegation. LPA met with Administrator Meghian Geul. On March 10, 2026, the Department received a complaint alleging Resident sustained multiple falls and bruises due to staff neglect. On March 18, 2026, Licensing Program Analyst Steve Chang Interviewed Administrator Meghian Geul, referred to as ADM. ADM stated on 3/9/26, at 8:00AM, staff S6 went to R1's room to get R1's breakfast order and found R1 on the floor of the bathroom. ADM stated R1 was trying to get shower and fell. The S6, contacted staff S1, who checked R1 and called 911 immediately. Emergency services arrived and R1 was sent to hospital. ADM stated the incident is an unwitnessed fall. Page 1 Out of 4 Unsubstantiated ADM stated facility cannot 100% prevent residents fall. ADM stated R1 is independent, with only escort care, wherein staff escort R1 to go to dining room and activity room, and escort R1 to return to his/her room. ADM stated R1 can walk inside his/her room. On March 18, 2026, LPA Steve Chang interviewed Staff S1-S5. S1 stated on 3/9/2026, at 8:00AM, S6 called him/her because R1 was found on the floor in the bathroom. S1 stated S6 was taking R1’s breakfast order to R1’s room and R1 was on the floor in the bathroom. S1 stated she went to R1's bedroom and observed R1’s left foot was bleeding. S1 stated he/she was trying to stop R1's bleeding and asked his/her coworker to call 911. S1 stated emergency responders came in about 3 minutes and R1 was sent to regional hospital. S2 stated R1 has standby assist for dressing and escort care. Staff S3 stated R1’s care was only escort care with some assistance with dressing. S3 stated R1 did not need assistance with showers or toileting. Staff S4 stated R1 is independent and is only on escort care. S5 stated he/she heard the incident is that R1 wanted to take a shower and slipped/fell at the bathroom. S4 stated R1 does not need assistance to transfer to and from bed. S5 stated R1 is not on status check care. On May 22, 2026, Licensing Program Analyst Manuel Monter and Steve Chang interviewed residents R2-R5. 4 Out of 4 Residents (R2-R5) stated they do not know R1. 4 Out of 4 Residents (R2-R5) stated they are not aware of any instance where a resident’s escorting or transferring needs were neglected. On May 22, 2026, Licensing Program Analysts Manuel Monter and Steve Chang interviewed staff members S7 through S11. S7 stated he/she does not remember how many falls R1 experienced. S7 and S8 reported that R1 is independent and does not require assistance with walking, escorting, or transfers. S8 stated that R1 has had three falls in the facility. S9 also reported that R1 sustained three falls, noting that the most recent fall resulted in R1 being sent to the hospital. S9 stated that R1 is independent and does not need assistance with walking, escorting, or transfers. S10 and S11 stated they do not know R1 and have not worked with R1. Page 2 Out of 4 On July 23, 2026, Licensing Program Analyst Manuel Monter interviewed R1. R1 stated he/she remembers faintly the fall he/she had back in March 2026. R1 stated that day he/she was walking near his/her bathroom when he/she tripped and fell. R1 stated he/she was rushing to answer his/her phone. R1 stated he/she didn’t press his/her pendant before he/she fell. R1 stated he/she didn’t think he/she needed help or predict that he/she would need the help. R1 stated prior to his/her fall in March 2026, the facility wouldn’t check on him, unless he/she pressed his/her pendant. The Department Reviewed resident R1’s Progress Notes. Progress Note Dated November 22, 2025: at 5:15pm, care giver called the medtech, noting that R1 had fallen. R1 had slipped on the floor and hit his/her buttocks. R1 denied hitting his/her head. Progress Note Dated December 14, 2025: at 4:30pm, R1 pushed his/her pendant and the care giver found R1 sitting on his/her buttocks, in his/her apartment closest. R1 claims he did not hit his/her head and did not have pain. Progress Note Dated December 16, 2025: Per R1, he/she stated he/she had a fall last night at 4:00am. R1 denies hitting his/her head and pain. R1 appeared confused and stated that his/her belongings are missing. Progress Note Dated December 20, 2025: At 2:49am, R1 reported to care giver that he/she had a fall besides his/her chair. R1 was assisted back to his/her chair. No complaints of pain or discomfort. Staff noted skin tear about 2 inches wide on his/her right elbow. Cleaned wound and applied bandage. Progress Note Dated December 23, 2025: At 10:27am, Care giver called for help, because he/she found R1 sitting on the floor. R1 denied hitting his/her head. Staff observed old skin tear on his/her right elbow bleeding. Progress Note Dated January 31, 2026: Around 9:20pm, R1’s Family member called asking to help R1. Staff went to R1’s room to check on R1. R1 stated he/she had lost his/her balance and fell on the floor. R1 denies hitting his/her head. Staff noticed bruise on his/her left arm. R1 stated he/she had it for a long time, refused to call 911. Page 3 Out of 4. Progress Note Dated February 24, 2026: at 11:20am, R1 was found lying on the floor. R1 stated that he/she had a fall while reaching his/her computer table. R1 denied hitting his/her head. R1 refused to call 911 and to be sent out to the hospital. Progress Note Dated March 9, 2026, states: at 8:30am, R1 was found lying on the floor in the bathroom, with visible bleeding. Resident was responsive but noted to have active bleeding from injury site (Left foot.) 911 was contacted. The Department reviewed R1’s Physician’s Report, dated March 8, 2025. R1 has auditory and visual impairment. R1 is non ambulatory and uses a walker. R1 is able to bath, dress him/herself. R1 is able to care for his/her own toileting needs. R1 is able to store and administer his/her own medications. The Department reviewed R1’s Service Plan, dated November 21, 2025. Based on a review, the service plan states R1 requires assistance with dressing in the morning, before breakfast daily. R1 requires escorting and or physical assistance to attend meals and or activities. R1 is at moderate risk for falling. Facility staff is to monitor for the use of glasses. Place pendant within reach of resident. Monitor and report changes in ambulation. The care team will monitor for changes in condition and conduct a reappraisal as appropriate. Based on investigation, records reviewed, and interviews conducted, R1 was generally independent with his/her ADLs with limited assistance; however, R1 had mobility limitations and was identified as being at risk for falls which resulted R1 sustaining injuries from falls. The Department was unable to establish whether the alleged neglect due to lack of care and supervision did nor did not contribute to R1’s injuries. Therefore, 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 allegations did or did not occur. Exit interview was conducted with Administrator, Meghian Geul and a copy of the report was provided. Page 4 Out of 4. End of Report.the state’s words, verbatim · CDSS document, Aug 6, 2026 · control 26-AS-20260310091638

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Manuel Monter arrived unannounced to deliver the results of a complaint investigation (26-AS-20260310091638). The purpose of this case management-other visit was to review and address concerns identified during the investigation of the above referenced complaint that are unrelated to the allegation. LPA met with Administrator Meghian Geul Reporting Requirements During the complaint investigation, R1’s facility file record was reviewed and identified multiple documented falls and injuries involving R1 from November 22, 2025- February 24, 2026. The Department reviewed R1’s Progress Note with the following noted observations: November 22, 2025: at 5:15pm, care giver called the medtech, noting that R1 had fallen. R1 had slipped on the floor and hit his/her buttocks. R1 denied hitting his/her head. December 14, 2025: at 4:30pm, R1 pushed his/her pendant and the care giver found R1 sitting on his/her buttocks, in his/her apartment closest. R1 claims he/she did not hit his/her head and did not have pain. December 16, 2025: Per R1, he/she stated he/she had a fall last night at 4:00am. R1 denies hitting his/her head and pain. R1 appeared confused and stated that his/her belongings are missing. December 20, 2025: At 2:49am, R1 reported to care giver that he/she had a fall besides his/her chair. R1 was assisted back to his/her chair. No complaints of pain or discomfort. Staff noted skin tear about 2 inches wide on his/her right elbow. Cleaned wound and applied bandage. Page 1 Out of 4 December 23, 2025: At 10:27am, Care giver called for help, because he/she found R1 sitting on the floor. R1 denied hitting his/her head. Staff observed old skin tear on his/her right elbow bleeding. January 31, 2026: Around 9:20pm, R1’s Family member called asking to help R1. Staff went to R1’s room to check on R1. R1 stated he/she had lost his/her balance and fell on the floor. R1 denies hitting his/her head. Staff noticed bruise on his/her left arm. R1 stated he/she had it for a long time, refused to call 911. February 24, 2026: at 11:20am, R1 was found lying on the floor. R1 stated that he/she had a fall while reaching his/her computer table. R1 denied hitting his/her head. R1 refused to call 911 and to be sent out to the hospital. The Department verified all incident reports (LIC624) submitted regarding R1 for the following date of incidents: 2/24/2026, 1/31/2026, 12/23/2025, 12/20/2025, 12/16/2025, 12/14/2025, 11/22/2025. Based on the review, the Department confirmed that the reports were not received. LPA discussed with Administrator, that the facility must submit incident reports for "Any incident which threatens the welfare, safety or health of any resident ". LPA noted that R1 is a resident who is over the age of 90 and any fall for this resident, is considered an incident that threatens his/her health and safety. LPA noted to ADM that progress note 12/20/2025, notes that R1 has sustained a skin tear about 2 inches wide. LPA noted 3 days later, on 12/23/2025, R1 had sustained another fall and it was observed his/her old skin tear was bleeding. LPA advised ADM to ensure, moving forward, any incident incident which threatens the welfare, safety or health of any resident, is reported to the Department of Social Services Community Care Licensing. LPA advised if facility staff is unsure if an incident needs to be reported, they can contact LPA Manuel Monter or contact the San Jose Regional office and speak to the desk duty officer of the day for clarification. ADM agreed and understood. Reappraisals During complaint investigation, it was R1 has auditory and visual impairment. R1 is non ambulatory and uses a walker. R1 is able to bath, dress him/herself. R1 is able to care for his/her own toileting needs. R1 is able to store and administer his/her own medications as per his/her Physician’s report, dated March 8, 2025. Page 2 Out of 4 The Department reviewed R1’s Service Plan, dated November 21, 2025. Based on a review, the service plan states R1 requires assistance with dressing in the morning, before breakfast daily. R1 requires escorting and or physical assistance to attend meals and or activities. R1 is at moderate risk for falling. Facility staff is to monitor for the use of glasses. Place pendant within reach of resident. Monitor and report changes in ambulation. The care team will monitor for changes in condition and conduct a reappraisal as appropriate. The Department interviewed staff S2. During interview with S2, the Department showed S2 R1’s progress notes, which documented that R1 had fallen 11/22/25, 12/14/25, 12/16/25, 12/20/25, 12/23/25, 1/31/26, 2/24/2026. The Department also showed S2 R1’s care plan, dated November 21, 2025. The Department asked if an assessment would be done after R1 fell on 12/14/25, 12/16/25, 12/20/25, 12/23/25, 1/31/26, and/or 2/24/2026. S2 stated based on the number of falls experienced by R1 during that time period of December - February, R1’s plan of care should have been reassessed. S2 stated R1 required more care and supervision than what he/she had, including assistance with dressing, showering, and transferring. On August 6, 2026, Licensing Program Analyst Manuel Monter interviewed Cathy Platon Health Services Director, referred to as HSD. The Department showed S2 R1’s progress notes, which documented that R1 had fallen 11/22/25, 12/14/25, 12/16/25, 12/20/25, 12/23/25, 1/31/26, 2/24/2026. The Department also showed S2 R1’s care plan, dated November 21, 2025. The Department asked if an assessment would be done after R1 fell on 12/14/25, 12/16/25, 12/20/25, 12/23/25, 1/31/26, and/or 2/24/2026. HSD stated based on the information presented regarding R1, there should have been an updated care plan or a care conference conducted to review R1's plan of care. The Department reviewed R1’s progress notes and observed the following: After R1’s care plan had been updated, the resident sustained one unwitnessed fall in November 2026. R1 then sustained four unwitnessed falls in December 2025. Additionally, R1 sustained one unwitnessed fall in January 2026, one in February 2026, and one in March 2026. Page 3 Out of 4. On July 20, 2026, the facility was cited a type B deficiency under the regulation the following regulation: 87463 Reappraisals (a) The pre-admission appraisal…shall be updated in writing as frequently as necessary … to note significant changes in condition… and to keep the appraisal accurate. …shall be referred to as the reappraisal. LPA advised ADM to ensure the facility takes an active role in the residents care plans, ensuring that care plans are updated in writing as frequently as necessary to note significant changes in condition and to keep the appraisal accurate. LPA advised ADM to take note if residents in care are sustaining numerous falls, the evaluate (with the residents responsible party if applicable) if the residents care plan needs to be updated to meet the needs of the resident. LPA provided ADM information regarding the Department’s Technical Support Program (TSP). During today's visit, the Department is issuing 2 technical violations. This report was reviewed with Administrator Meghian Geul and a copy of the report was provided. Page 4 Out of 4 End Of Report.the state’s words, verbatim · CDSS document, Aug 6, 2026

Allegation investigated: Facility staff neglected resident in care resulting in resident sustaining injuries

Licensing Program Analysts (LPAs) Manuel Monter and Simi Rai conducted an unannounced complaint inspection/investigation to deliver the findings on the above allegations. LPAs met with Administrator, Meghian Guel and stated the purpose of today's visit. On November 10, 2025, the Department received a complaint alleging facility staff neglected resident in care resulting in resident sustaining injuries. Based on investigation, on November 13, 2025, and April 28, 2026, the Department interviewed a witness (referred as W1). W1 stated resident (referred as R1) was a resident of the facility for 2 years. W1 stated he/she is aware of R1’s history of fall incidents wherein it’s been reported R1 having at least 5 falls in the last 3 years. Continuation on LIC 9099-C, Page 1 of 5. Unsubstantiated Page 2 of 5. W1 stated R1 was independent and known for not calling for assistance, by not utilizing his/her call button. On 11/9/2025, R1 was taken at the hospital because R1 had an unwitnessed fall in his/her bedroom. W1 stated that R1 sustained injuries on his/her face, neck and extremities reported by the hospital/medical skilled professional. W1 stated R1 had a recurring sore on R1’s right shin due to poor circulation. W1 also added that R1 was on blood thinning medications that made him/her susceptible to bruising. W1 stated it was normal for R1 to have bruises on his/her legs due to “very poor circulation in his/her legs.” W1 stated two weeks prior to 11/9/2025, R1 was trying to open a drawer from under the sink when the door popped open and “got him/her in the face.” Based on review of residents’ medical and facility records, there was no report that the said incident occurred or that R1 sustained an injury to his/her face. Moreover, W1 stated R1 was always hitting his/her legs on the couch, table, bed post, and toilet that caused bruising due to his/her right foot amputation which affected his/her mobility or ambulation. Based on review of R1’s physician’s report dated May 19, 2025, R1 was visually and auditory impaired and required physical assistance with bathing but was otherwise independent. R1 used a walker due to right foot amputation, was considered non-ambulatory due to his/her physical condition and could not leave the facility unassisted. In April, May and June 2026, the Department interviewed 7 staff (referred as S1-S7). Based on interviews, S1 stated that although he/she had limited interactions with R1 and resident (R1) declined assistance on two occasions. S1 stated that staff are assigned to residents of each scheduled shift; staff have a list of residents assigned to them. S1 stated that he/she found it unusual that R1 was not included on the assignment list. S1 stated that while R1 can perform some of his/her ADLs, he/she still requires assistance and is not considered fully independent. S2 stated that R1 required assistance for showering; however, he/she was otherwise independent. S2 stated R1 used a walker and was considered at risk for falls. S1 reported that he/she was not present at the facility on 11/9/25, when R1 fell, and was not aware of the incident. Page 3 of 5. S3 stated that R1 was hard of hearing and required assistance with laundry and showering. S3 further stated that R1 was ambulatory and used a walker for mobility. S3 reported that he/she was not working on 11/9/25 and was therefore not aware of R1’s fall on that date. S1 stated that he/she did not recall being informed about the two falls reportedly occurred on 11/8/25. S1 further stated that he/she did not recall observing any bruising on R1’s face or extremities on 11/09/2025. S4 stated he/she had only assisted R1 once or twice and he/she was not aware of R1’s medication regimen, as R4 self-managed his/her medications. S4 stated that he/she did not know whether R1 was identified as a fall risk; however, he/she is aware that R1 required two-hour checks. S4 was asked about R1’s other falls reportedly on 06/28/2025, 08/21/2025, and 10/23/2025; however, S4 stated he/she had no knowledge of these incidents and was unable to provide information regarding the falls. S4 recalled seeing a bruise on R1’s chin and neck but did not recall the date. S4 believed the fall occurred prior to R1’s hospitalization and described R1 as having a large and dark purple discoloration. S4 stated did not recall whether the bruise was documented [in R1’s facility chart]. S5 stated R1 only required assistance with showering. S5 recalled assisting R1 with his/her ADLs once. S5 stated he/she was not working on 11/09/2025 and therefore was not aware of R1’s fall on that date. S5 stated he/she was not aware of how many falls R1 had experienced while at Ivy Park. S5 was also unable to provide information regarding what fall prevention measures were in place for R1 aside R1’s call button pendant. S6 stated he/she never took care of R1 because R1 was generally independent but required assistance with showering. S6 stated that R1 had a history of frequent falls prior to his/her death and recalled the last two falls that occurred before R1 was hospitalized. S6 was unable to recall the exact date of the incident but stated that R1 was observed in the morning after the fall. S6 stated that R1’s family was present during the evening, and after the family left, R1 appeared to be “okay”. S6 reported that R1 later stated that he/she tripped on his/her carpet and fell, landing on his/her face. S6 stated he/she did not observe any bruising on R1’s face or neck following that fall. Page 4 of 5. During investigation interview with S6, the Department showed S6 the alert charting notes for R1, which documented that R1 had fallen and hit his/her head on 11/08/2025. S6 stated that he/she was still new to working at Ivy Park at the time of the incident. S6 stated that he/she was aware of one fall that occurred earlier in the day and that he/she contacted R1’s responsible party about the incident. S6 stated R1 indicated he/she was okay following the incident and that another staff (S2) was also present at the time. S6 acknowledged that he/she could have followed up with the Resident Care Coordinator (RCC) regarding the incident but failed to do so and was unable to provide a reason. S6 stated that he/she did not recall observing any bruising on R1’s face, neck or extremities, explaining that the incident occurred a long time ago and he/she could not remember. S7 stated that he/she was not familiar with R1 and had never met him/her. The Department informed S7 that R1 was a resident of assisted living (AL) who required assistance with showering, and had sustained multiple falls, on 10/23/2025, and additional falls on 11/08/2025, and 11/09/2025. S7 stated that no staff member reported these incidents to him/her, had he/she been notified, he/she would have arranged for R1 to be sent to the hospital sooner. S7 added that staff did not consult with him/her or request that he/she conduct a re-assessment of R1 following the falls. The Department reviewed R1’s Charting Notes (CN) with the following noted observations: · On 6/29/25 R1 sustained a fall. · On 8/21/25, S2 observed discoloration on R1’s right lower leg and forehead that was a few days old, wherein R1 stated he/she had hit his/her head and denied falling. · On 10/23/25, R1 reported he/she had lost his/her balance and hit his/her head and sustained a bruise on his/her right check and right side of his/her chin. · On 10/24/25, Staff noted that R1 stated he/she bumped his/her head on the coffee table. R1 said the bruise to his/her face and chin was from a fall a few weeks ago. · On 11/8/25, staff and W1 noted R1 had fallen around 1:20pm. Later in the evening, around 7:15, R1 was found on the floor by a staff. S6 assessed R1, who stated he/she had hit his/her forehead. · On 11/9/25, around 5:00pm, R1 was found on the floor. Page 5 of 5. The Department reviewed R1’s service plan, dated July 5, 2025. The service plan indicated that R1 requires maximum assistance with bathing. The service plan further documented that R1 did not require assistance with dressing, grooming, oral care, toileting, or transferring. R1 used a walker for mobility and was able to feed him/herself. Based on investigation, records reviewed, and interviews conducted, R1 was generally independent with his/her ADLs with limited assistance; however, R1 had mobility limitations and was identified as being at risk for falls which resulted R1 sustaining injuries from falls. The Department was unable to establish whether the alleged neglect due to lack of care and supervision did nor did not contribute to R1’s injuries. Therefore, 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 allegations did or did not occur. Exit interview was conducted with Administrator, Meghian Geul and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 20, 2026 · control 26-AS-20251110154451

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Manuel Monter arrived unannounced to deliver the results of a complaint investigation (26-AS-20251110154451). The purpose of this case management-other visit was to review and address concerns identified during the investigation of the above referenced complaint that are unrelated to the allegation. LPA met with Administrator, Meghian Geul. Reporting Requirements During the complaint investigation, R1’s facility file record was reviewed and identified multiple documented falls and injuries involving R1 from 8/21/25 to 11/8/2025. Based on interview with ADM, ADM admitted that the required incident reports were not submitted to CCLD within the regulatory 7 days time frame. The Department reviewed R1’s Charting Notes (CN) with the following noted observations: On August 21, 2025, S2 observed discoloration on R1’s right lower leg and forehead that was a few days old, wherein R1 stated he/she had hit his/her head and denied falling. On October 23, 2025, R1 reported he/she had lost his/her balance and hit his/her head and sustained a bruise on his/her right check and right side of his/her chin. On October 24, 2025, Staff noted that R1 stated he/she bumped his/her head on the coffee table. R1 said the bruise to his/her face and chin was from a fall a few weeks ago. On November 8, 2025, staff and Witness W1 noted R1 had fallen around 1:20pm. Later in the evening, around 7:15, R1 was found on the floor by a care giver. S6 assessed R1, who stated he/she had hit his/her forehead. Continuation on LIC 809-C, Page 1 of 6. The Department verified all incident reports (LIC624) submitted regarding R1 for the following date of incidents: 8/21/2025, 10/23/2025, 10/24/2025, 11/8/2025. Based on the review, the Department confirmed that the reports were not received. The ADM acknowledged that the required incident reports had not been submitted. Arranging in Medical Care. The Department reviewed R1’s Charting Notes (CN) with the following noted observations: On November 8, 2025, staff and Witness W1 noted R1 had fallen around 1:20pm. Later in the evening, around 7:15, R1 was found on the floor by a care giver. S6 assessed R1, who stated he/she had hit his/her forehead. In April, May, & June 2026, the Department interviewed staff 4 staff (referred as S4-S7). S4 stated he/she had only assisted R1 once or twice and he/she was not aware of R1’s medication regimen, as R4 self-managed his/her medications. S4 stated that he/she did not know whether R1 was identified as a fall risk; however, he/she is aware that R1 required two-hour checks. The Department read S4’s notes that he/she documented and confirmed that R1 fell and hit his/her head on 11/08/2025 at 1915 hours, which S4 said, “Yes.” Initially S4 was unable to answer regarding why R1 was not sent out to the hospital on 11/08/2025 but later said that R1 may have refused to go to the hospital. S4 stated that staff would obtain a copy of the signed refusal from EMS and would document that 911 was called and that the resident refused to go to the hospital. S4 was unable to tell why it was not documented that 911 was called and that R1 refused to be sent to the hospital. The Department asked S4 about R1’s other falls on 06/28/2025, possibly 08/21/2025, and 10/23/2025 but S4 did not know anything about those falls and was unable to provide information about those falls. The Department requested a copy of the signed refusal and S4 said that staff never obtained a copy of the refusal and that EMS would have it. S5 stated R1 was not under the medication management program and only required showering assistance. The Department showed S5 the charting notes from 11/08/2025, and S5 stated that R1 should have been sent out to the hospital because he/she hit his/her head. S5 stated If 911 was called and R1 refused to go to the hospital, it should have been documented as well. Page 2 of 6. S6 stated he/she never took care of R1 because R1 was generally independent but required assistance with showering. S6 stated that R1 had a history of frequent falls prior to his/her death and recalled the last two falls that occurred before R1 was hospitalized. S6 did not recall the date but said that R1 fell in the morning when his/her family was present, and in the evening after R1’s family left. S6 stated R1 was “okay” after falling in the evening and said that he/she was trying to get his/her phone from the side table. S6 stated he/she was trained to call 911 if a resident hit their head after a fall. S7 stated if a resident hits their head after falling, it is an “automatic send out” to the hospital. S7 stated Ivy Park does not adhere to the fall prevention protocol and there are no prevention methods in place other than “just checking on them.” S7 stated he/she did not know R1 and never met him/her. S7 added that R1 should have been sent out following the evening fall on 11/08/2025 since she hit his/her head. S7 said that no one had reported R1’s falls to him/her, otherwise he/she would have sent R1 out to the hospital sooner. The Department reviewed Local Fire Department Records. A review noted there were no calls for service between 11/06/2025 through 11/08/2025 for R1. A Review of Local Fire Department Patient Care Report states, on 11/09/2025, at or around 1721 hours, a 911 call was made for a complaint of altered level of consciousness. R1 had lost his/her hearing aid, had signs of old falls and bruising on his/her face, hands, and legs. Paramedics noted during their primary assessment that there were signs of old bruising, low blood sugar, and elevated heart rate. R1 was unable to communicate with EMS personnel and was transported to the hospital. The Department Reviewed Local Law Enforcement Dispatch Reports. There were no calls for service for R1 on 11/8/2025. Based on the investigation, there is no documented evidence indicating that the facility contacted 911 after Resident 1 (R1) sustained two falls on November 8, 2025. However, Staff 4 (S4) stated that R1 may have refused transport to the hospital; yet S4 was unable to provide documentation confirming that R1 declined or refused medical treatment or transportation. There is not a preponderance of evidence to prove nor disprove that the allegation, that the facility neglected to contact emergency services after R1’s fall on November 8, 2025. Page 3 of 6 Reappraisals During complaint investigation, it was noted that R1 requires assistance with bathing/showering but was otherwise generally independent. R1 used a walker due to mobility and visual and auditory impairment as per his/her Physician’s report, dated 04/14/2025. The Department reviewed R1’s service plan, dated July 5, 2025. The service plan indicated that R1 requires maximum assistance with bathing. The service plan further documented that R1 did not require assistance with dressing, grooming, oral care, toileting, or transferring. R1 used a walker for mobility and was able to feed him/herself. In April, May, & June 2026, the Department interviewed 5 staff (referred as S1, S4-S7). S1 stated that although he/she had limited interactions with R1; S1 reported that the resident (R1) declined assistance on two occasions. S1 stated that staff are assigned to residents of each scheduled shift; staff have a list of residents assigned to them. S1 stated that he/she found it unusual that R1 was not included on the assignment list. S1 stated that while R1 can perform some of his/her ADLs, he/she still requires assistance and is not considered fully independent. S4 stated he/she had only assisted R1 once or twice and he/she was not aware of R1’s medication regimen, as R4 self-managed his/her medications. S4 stated that he/she did not know whether R1 was identified as a fall risk; however, he/she is aware that R1 required two-hour checks. The Department asked if an assessment would be done after R1 fell on 06/29/2025, possibly 08/21/2025, 10/23/2025, 11/08/2025, and 11/09/2025, and S4 said, “Yes. One should have been done for each fall.” S4 did not know whether one was done for each of R1’s falls. S4 recalled seeing a bruise on R1’s chin and neck but did not recall the date. S4 believed it may have been prior to R1’s hospitalization. S4 described the bruise as large and dark purple in color. S4 did not recall whether the bruise was documented in R1’s chart. Page 4 of 6 S5 stated R1 only required assistance with showering. S5 recalled assisting R1 with his/her ADLs once. S5 stated he/she was not working on 11/09/2025 and therefore was not aware of R1’s fall on that date. S5 stated he/she was not aware of how many falls R1 had experienced while at Ivy Park. S5 was also unable to provide information regarding what fall prevention measures were in place for R1 aside R1’s call button pendant. S6 stated he/she never took care of R1 because R1 was independent but required assistance with showers. S6 stated R1 was “always falling” before he/she died. S6 recalled the last two falls R1 had before he/she was hospitalized. S7 stated he/she did not know R1 and never met him/her. The Department explained that R1’s last care plan was completed on 07/05/2025. S7 stated that a re-assessment should have been done on 10/23/2025 and on 11/08/2025. S7 added that no one consulted with him/her nor asked him/her to conduct a re-assessment of R1. S7 believed R1 required a higher level of care than what he/she received. S7 said it was important that re-assessments were done in a timely manner. The Department reviewed R1’s Charting Notes (CN) with the following noted observations: On June 29, 2025, staff was letting W1 in when W1 informed him/her that R1 had fallen on June 28, 2025. Memory Care director assessed R1 and contacted 911. On August 21, 2025, S2 observed discoloration on R1’s right lower leg and forehead that was a few days old, wherein R1 stated he/she had hit his/her head and denied falling. On October 23, 2025, R1 reported he/she had lost his/her balance and hit his/her head and sustained a bruise on his/her right check and right side of his/her chin. On October 24, 2025, Staff noted that R1 stated he/she bumped his/her head on the coffee table. R1 said the bruise to his/her face and chin was from a fall a few weeks ago. On November 8, 2025, staff and Witness W1 noted R1 had fallen around 1:20pm. Later in the evening, around 7:15, R1 was found on the floor by a care giver. S6 assessed R1, who stated he/she had hit his/her forehead. Page 5 of 6 Based on documents reviewed and interviews conducted, the facility did not re-assess resident R1 after he/she sustained falls in the facility on 08/21/2025, 10/23/2025, 11/08/2025. Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Administrator, Meghian Guel and a copy of the report and appeal rights were provided. Page 6 of 6the state’s words, verbatim · CDSS document, Jul 20, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Jul 27, 2026

87211 Reporting Requirements (a)(1)(D) Any incident which threatens the welfare, safety, or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by: Based on interviews and records reviewed of incident reports submitted to the Department, incident reports were not filed with the licensing agency regarding a change of condition wherein R1 had falls on 08/21/2025, 10/23/2025 and 11/08/2025, which poses/posed a potential health,the state’s words, verbatim · CDSS document, Jul 20, 2026

Plan of correction: Administrator stated she will conduct an inservice training with her staff and submit to CCL by POC due date. Administrator agreed and understood. (con't) safety or personal rights risk to persons in care.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87463(a) · Plan of correction due date: Jul 27, 2026

87463 Reappraisals (a) The pre-admission appraisal…shall be updated in writing as frequently as necessary … to note significant changes in condition… and to keep the appraisal accurate. …shall be referred to as the reappraisal. This requirement is not met as evidenced by: Based on record review, R1 did not have a reappraisal after sustaining falls on 08/21/2025, 10/23/2025 and 11/08/2025 which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 20, 2026

Plan of correction: Administrator stated will conduct an inservice training with her staff and submit to CCL by POC due date. Administrator agreed and understood.

Type of visit: Case Management - Other

Licensing Program Analyst Manuel Monter arrived on July 14, 2026 for an unannounced inspection to follow up on a substantiated allegation of complaint investigation. On February 23, 2024, the Department concluded a complaint report investigation regarding the following allegations: staff neglected a resident resulting in multiple fractures, licensee does not adequately staff facility to meet residents’ high level of care and needs, and staff did not submit incident report to Licensing. The licensee was cited for California Code of Regulations (CCR) Title 22 § 87466 Observation of the Resident, CCR 87465(a)(1) Incident Medical and Dental Care, CCR 87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities, CCR 87211(a)(1)(D) Reporting Requirements, and CCR 87463(a) Reappraisals. At the time of the complaint visit on February 23, 2024, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49(f). The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code Section 15610.67 define serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by the licensee did not provide care and supervision for resident resulting in the resident sustaining a fractured finger and ribs that resulted in Serious Bodily Injury. Today, July 14, 2026, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49(f) for a violation that the Department constitutes as serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on February 23, 2024, the amount of the civil penalty issued today will be $9,500. Exit interview conducted. A copy of the report issued. Appeal rights provided. Administrator Meghian Geul and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Jul 14, 2026

Allegation investigated: Staff do not answer resident pull cords in a timely manner.

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation visit and met with Executive Director (ED) Meghian Geul. On 09/04/2025, the Department received a complaint with the allegation that staff do not answer resident pull cords in a timely manner. On 09/04/2025, the Department conducted an initial investigation visit. LPA interviewed ED, 2 staff and 2 residents. Continue on LIC9099-C. Page 1 of 3. Unfounded The allegation is that staff did not answer resident's pull cord in a timely manner. On 09/03/2025, at 01:00AM, R1 pulled the emergency cord in his/her bathroom but the facility staff did not respond to it. ON 10/03/2025, LPA interviewed Executive Director (ED) Meghian Geul. ED stated the facility staff were not alerted when R1's call for assistance through his/her emergency cord on 09/03/2025 at 1:00AM. ED stated based on the emergency call alarm pull cord button log, the facility emergency call system did not receive the emergency notification from R1's room on 09/03/2025. ED stated there was training provided to staff and medication technicians that emergency pull alarm cord string cannot be tied on the toilet paper holder rack. On 10/03/2025, LPA interviewed Maintenance Director (MD). MD stated the maintenance department reviews the pull cord alarm system log every week to check for any issues such as low battery and fixes issues immediately. MD confirmed that the facility staff were not alerted when R1 called for assistance per alarm system log. On 09/03/2025 at 8:00AM, R1 called the front desk to inform that he/she had pulled his/her emergency alarm pull cord at 1:00AM but no one respond. A caregiver went to help R1 and checked R1's emergency alarm pull cord; and placed a work order to notify MD to check/fix. On the same day, at 10:00AM, MD stated he/she went to R1's apartment/bedroom to check on R1's emergency pull cord alarm. MD found that the emergency alarm pull cord string was tied/wrapped around the toilet paper holder rack tightly, and was unable to activate alarm when pulling the pull cord. MD stated he/she untied the emergency alarm cord string from the toilet paper holder rack, and R1's emergency pull cord was fixed and it alerts staff when pulling the emergency cord. MD stated that he/she provided training to facility staff including housekeepers prior to this incident reminding them not to tie or wrap emergency alarm pull cord to toilet paper holder rack. On 10/07/2025, LPA interviewed resident R1. R1 stated he/she was unable to remember if the emergency pull alarm cord string was tied or wrapped on the toilet paper holder rack on 09/03/2025 at 1:00AM. Continue on LIC9099-C. Page 2 of 3. On the same day, LPA noted that R1's emergency pull alarm cord string was untied to the toilet paper holder rack. LPA also tested by pulling the emergency pull alarm cord, and 2 staff came into R1's room within 5 minutes. LPA also tested the emergency pull alarm cord system by tying it on the toilet paper holder rack to see if pulled would alert staff radio while the 2 staff were observing, staff radio did not alert them. Based on interviews, record review and inspection of R1’s Emergency pull alarm cord and emergency log confirms that staff did not alert them when R1 called for assistance. It was discovered by staff that R1’s emergency pull alarm cord was wrapped or tied to the toilet paper holder rack which prevents it from activating. The Department has investigated the above allegation. 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, Mar 18, 2026 · control 26-AS-20250904105025

Allegation investigated: Staff did not implement a proper facility emergency plan.

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation finding and met with Executive Director (ED) Meghian Geul. On 12/29/2025, the Department received a complaint with the allegation that the facility staff did not implement a proper facility emergency plan. On 01/06/2026, the Department conducted an initial investigation visit. LPA interviewed ED, 6 staff and 4 residents. LPA reviewed the facility Emergency Plan Package with ED. LPA obtained a copy of the Emergency and Disaster plan and facility utility outage plan. Continue on LIC9099-C. Page 1 of 3. Unfounded On 12/29/2025, the Department received an incident report from the facility. The incident report stated that on 12/26/2025 around 3:00AM there was a loud noise outside the facility, the power box on the street had a bad parts and needed to be repaired. A power outage happened at the facility due to PG&E. The facility contacted PG&E and PG&E stated the power would be back at 2:45PM on 12/26/2025 then later changed to 9:00PM on 12/26/2025. The power was restored at 11:00PM on 12/26/2025. The facility notified the residents and staff about the power outage incident. The facility culinary team was starting to prepare all meals to deliver to resident rooms. Staff were asked to station at the 3 exit doors in memory care unit until power was restored to make sure memory care residents to stay in memory care unit. Staff conducted hourly checks and head counts on all residents. Residents that needed to come down to first floor or to go upstairs were helped by the facility staff to use evacuation chairs. Residents were provided with flashlights and extra blankets if needed. The residents families were informed and a mass email was sent to families on 12/27/2025. On 01/06/2026, LPA interviewed Executive Director (ED) Meghian Geul. ED stated the power outage was an unplanned and non announced incident from PG&E. ED stated the power outage started around 2:45AM on 12/26/2025 and the power restored at 11:00PM 12/26/2025. ED stated there were emergency lighting in the walkway for 90 minutes, then battery lamps were placed at the walkways. ED stated Memory Care residents were checked every 30 minutes and Assisted Living residents were checked every hour. MD stated all meals (breakfast, lunch, and dinner) were delivered to resident rooms. ED stated some residents wanted to leave the facility during the power outage period, the staff helped the residents to use the evacuation chairs to go to the first floor. ED stated the facility staff delivered extra blankets and flashlights to residents if needed. ED stated staff were at the exit doors of the memory care unit to make sure memory care residents to stay in memory care unit. ED stated the facility kept all memory care residents at the activity room in the memory care unit during the day time and provided activity to residents. LPA interviewed Maintenance Director (MD). MD stated the power outage on 12/26/2025 is an unannounced power outage. MD stated The facility has a backup power for 90 minutes. MD stated the facility will rent a generator if the power outage more than 24 hours. MD stated the hallways and stairs were provided emergency lighting. Continue on LIC9099-C. Page 2 of 3. MD stated staff helped residents to go downstair by using evacuation chairs at stairs. MD stated all meals were delivered to resident rooms. MD stated residents were provided flashlight and blankets. MD stated power was restored at 11:00PM on 12/26/2025. LPA interviewed 4 staff. 4 Out of 4 staff stated residents were regularly checked and monitored during the power outage. 4 Out of 4 staff stated all meals were delivered to resident rooms, flashlights and blankets were provided to residents during the power outage. LPA interviewed 4 residents. 4 Out of 4 residents stated they did not have any issue during the power outage. 4 Out of 4 residents stated meals, flashlights and blankets were provided. 3 Out of 4 residents stated they did not have compliant. 1 Out of 4 residents stated he/she did not have complaint but some other residents might have complaints. Based on the review of the facility emergency plan dated 9/20/2025, the plan including the following but not limit to, "each stair has an evacuation chair to use as needed, to communicate with emergency service agencies, responding to individual resident's needs and checking residents every 15 minutes until power restores, resident using oxygen concentrator will have appropriate backup oxygen tank available, communication with residents and families, assisting resident for administering medications, storage and preservation of medications, Identifying residents with special needs such as hospice care". Based on the review of the facility Utility Outage plan document, the plan has the procedures for "Prepare for Power Outage", "During a Power Outage", and "After the Power Outage". Based on the interview and record review, the facility has a proper facility emergency plan, and staff conducted and followed the emergency plan for the incident. 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. Exit interview was conducted with ED. The report was provided to ED for review. A copy of the report was provided to ED. Page 3 of 3.the state’s words, verbatim · CDSS document, Mar 5, 2026 · control 26-AS-20251229093034

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

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced Case Management for a Non-Compliance Plan Quarterly Visit and met with Administrator (ADM) Meghian Geul. The purpose of the visit is to ensure the facility is adhering to the Compliance Plan submitted to Community Care Licensing (CCL) after an informal meeting held on 04/26/2024. LPA toured the memory care unit and tested the exit doors in the memory care unit with ADM. The exit doors made auditory sound when pressed and needs to enter the correct code to open. LPA tested the gate of the courtyard of memory care unit. The gate needs to enter correct code to open. LPA toured Med room of memory care unit. The Med room was observed locked and two Med Carts were observed in the Med Room. LPA reviewed staff in-service training log in December 2025 - February 2026 including but not limited to on topics : Medication error prevention, Resident right to privacy, reporting change in condition, reporting requirement and Elopement drill training. The case management of inspections will be conducted every 3 months for 2 years. No citation noted today. Exit interview was conducted with ADM. The report was provided to ADM for review and for signature. A copy of the report was provided to ADM.the state’s words, verbatim · CDSS document, Feb 24, 2026

Type of visit: Case Management - Other

On 01/16/26 Licensing Program Analyst (LPA) Marcela Yanez conducted an unannounced complaint investigation visit to amend the complaint delivered on 12/30/25 (26-AS-20241017082303) and met with Executive Director (ED) Meghian Geul and announced the purpose of the visit. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Executive Director Meghian Geul and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 16, 2026

Allegation investigated: Facility is charging services not agreed on the admission agreement.

THIS IS AN AMENDED REPORT On 01/16/26 LPA Yanez amended report and met with Meghian Geul. On 12/30/25 Licensing Program Analyst (LPA) Marcela Yanez conducted an unannounced visit to deliver the findings of the complaint investigation. LPA met with Meghian Geul, Executive Director and stated the purpose of the visit. On 07/25/2025, Licensing Program Analyst (LPA) Marcela Yanez conducted an unannounced visit to deliver the finding of the complaint investigation. LPA met with Jmy Ramos, Assisted Living Director and stated the purpose of the visit. On 09/04/25 LPA Marcela Yanez and LPM Romeo Manzano met with Executive Director Meghian Geul to amend the report to “needs further investigation” due to the Department receiving new information. During visit LPA obtained additional documents of R1 and R2 and interviewed staff. Unfounded Page 2 of 4 10/17/2024 - Department received a complaint with the above allegation. On10/24/2024 and 3/8/2025, the department conducted an initial complaint investigation. LPAs requested copies of documents, interview staff, resident and reporting party. On 10/17/2024 LPA interviewed RP during intake and stated that he/she on multiple occasions have asked to explain charges and when payments are received and how the late fees are assessed by the facility. RP stated that the record does not reflect the time payment was received and when checks were cashed by the facility On 10/25/2024, the Department conducted an initial complaint investigation and interviewed staff (S1 and S2). Based on interview S1 stated he/she is not aware of the details of the complaint but is aware that the resident (R1) was making partial payments every month which would then accrue a late fee. S2 stated R1 was accruing a late fee because he/she was not making a full complete payment that was due to the facility. S2 stated that R1 followed the post it note and not what was given to him/her by the previous finance director and did not follow the billing invoice that was sent to R1 each month. S2 stated that the fees have been reversed and refund was issued to R1 when the problem was sorted out. Based on record review, facility and R1 entered into agreement on 9/29/2022. On the admission agreement a late fee will be assessed and incurred by the R1 if payment is late or not paid in full. Based on the agreement the resident is to fulfill obligation every 5th of each month. (page 10 of the admission agreement). Stipulated on the admission agreement is the adjustment of services and changes in care services. On page 27 of the admission agreement (Appendix B) is the list of additional items/service that may incur additional cost on top of the rental fee that was required to be paid on time by the R1. R1 was given a post-it note for one of the monthly rental payment, and was also given a monthly statement of what R1 owed. The resident does not go by the statement by instead was going by the handwritten post-it note not that was given to him/her by the former Business Director. Page 3 of 4 Based on document review, the resident was being charged a late fee due to non-payment of the full amount of the rent. Based on document review - the facility has refunded all of the late fees that the resident incurred from two years ago to present. There were no charges for a service not render and charged without the resident's knowledge. On 09/04/25 the complaint findings was changed from unfounded to needs further investigation to review additional information provided by the RP and documents provided by the facility. On 07/28/25 RP submitted additional documentation for proof of payment for facility fees that R1 and R2 were charged. RP submitted canceled checks for R1 and R2 from 2023-2024 and RP alleged the facility incorrectly charged Wanderguard fee and erroneously charged fees. Documentation provided by RP was reviewed on 10/25/24, 1/16/25, 3/02/25, 07/25/25, 07/28/25, 07/29/25, 09/10/25, 09/12/25, 09/15/25, 09/23/25, 09/26/25 by LPA Yanez and LPA Partoza. The Department reviewed the documents RP provided and matched documents to the facility documents all payments made to the facility were credited to R1 and R2s account. The canceled checks provided by RP reflected payments made on R1s and R2s account were not what was due on the monthly statement record and a balance was carried over each month accruing non-sufficient fees (NSF) and late fees. These late fees and NSF fees were credited to R1 and R2s account in the amount of $1217.00 dollars as a courtesy by the facility. R1s and R2s admission agreement stated that the residents would not be charged a $150-dollar Wanderguard fee for a promotional period. The Wanderguard fee was waived from 10/04/22 to 08/18/23. Wanderguard fee was charged for 6 months from 09/20/23 when R2 was moved into memory care until R2 moved out of facility on 03/23/24. R1 signed the admission agreement and agreed to the Wanderguard fee totaling $150 a month. On 04/03/24 R2 was credited $150 dollars for 1 month and a prorated amount of $33.88 upon R2s moving out of facility. Page 4 of 4 R1 and R2 received multiple concession credits and promotional discounts agreed upon by the admission agreement signed by R1 on 09/29/22. On 12/29/25 the department completed its investigation from the additional information provided by RP. This department has investigated the complaint alleging that the facility is charging services not agreed on the admission agreement. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. No deficiency is cited during today's visit based on California Code of Regulations (CCR) Title 22. An exit interview was conducted with Meghian Geul, Executive Director and a copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 30, 2025 · control 26-AS-20241017082303

Allegation investigated: Facility did not ensure resident's room was kept in a clean, safe, and sanitary manner.

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliverer investigation finding and met with Executive Director (ED) Meghian Geul. On 04/29/2025, the Department received a complaint with the allegation that facility did not ensure resident's room was kept in a clean, safe, and sanitary manner. On 05/07/2025, an initial investigation visit was conducted. LPA toured resident room, and interviewed ED, 10 staff and 7 residents. LPA requested resident roster, LIC500, resident shower schedule, laundry schedule, resident physician report, assessment and care plan. ED provided staff in service training sheet and action plan. Continue on LIC9099-C. Page 1 of 3. Unfounded On 05/07/2025, LPA interviewed Executive Director (ED) Meghian Geul. ED stated housekeepers clean resident rooms once per week. ED stated caregivers take out trash from resident room after they visit residents. ED stated caregivers visit/check residents more often to take out soiled diapers/trash if residents are incontinent. ED stated residents receive 2 showers per week. ED stated residents have laundry service once per week and as needed. LPA interviewed Housekeeper/Maintenance Director (HD). HD stated housekeepers clean resident rooms once per week. HD stated housekeepers conduct laundry for residents' bed sheets and linens once per week. HD stated that caregivers conduct laundry for residents' clothes. LPA interviewed previous Director of Assist Living Unit (DAL), DAL stated housekeepers clean resident room once per week. DAL stated housekeepers conduct laundry of bed sheets and linens for residents once per week and caregivers conduct laundry of resident clothes once per week. DAL stated caregivers take out trash for residents when they visit resident rooms. LPA interviewed 7 caregivers, 7 out of 7 caregivers stated they take out trash for residents when they visit resident rooms. LPA toured resident R1's room and interviewed R1. R1 stated housekeepers clean the room once per week. R1 stated caregivers take out trash from the room when they visit the room. LPA observed washing machine and drying machine in the room. LPA did not observe trash on the floor or on table in the room. LPA did not observe many soiled clothes in the laundry basket. R1's room was clean and in sanitary condition. LPA toured 7 other resident rooms and interviewed 7 residents. 7 out of 7 residents stated housekeepers clean their rooms once per week. 7 out 7 residents stated laundry was conducted at least one time per week by the facility staff or by themselves. No trash was observed on the floor or on table in the rooms. The rooms were observed clean and in sanitary condition. Continue on LIC9099-C. Page 2 of 3. On 5/21/2025, LPA toured 8 resident rooms. LPA observed the bedrooms and bathrooms as clean, sanitary and in good condition. LPA did not note any foul odor in the residents' bedrooms or bathrooms. Based on the observation and interview with staff and residents, residents' rooms were observed as clean, in sanitary condition and in good condition. The facility staff clean resident rooms once per week and conduct laundry once per week. Caregivers take out trash for residents when they visit resident rooms. 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. On 05/07/2025, LPA interviewed Executive Director (ED) Meghian Geul, previous Director of Assisted Living (DAL), and Housekeepers Director (HD). Based on the interview with ED and DAL, resident R1 moved in the facility on 08/25/2022, and before 04/01/2025 R1 was independent and only received medication management assistance with getting changed clothing during morning and bedtime care. On 04/01/2025, R1's care/service plan has been updated due to change of health condition. R1 requires incontinence assistance and taking baths. R1 was provided bathing every Sunday, Tuesday and Thursday at 6:30PM. During interview with HD regarding R1's dirty laundry, HD stated residents' laundry is washed weekly. HD stated also he/she did not receive a request from management until 05/06/2025 that R1's laundry has to be washed from one to three times a week. On 05/07/2025, LPA conducted a random interview with 7 staff (S1 - S7) regarding R1's dirty laundry. 3 Out of 7 staff stated the facility does not have the resident laundry log, they were unable to remember the dates that they conducted laundry for R1. On 05/07/2025, LPA conducted a random interview with 7 staff regarding R1's shower/bathing, 3 Out of 7 staff (S1- S3) stated they have assisted R1 with showers/bating for the following dates 04/13/2025, 04/15/2025, 04/29/2025, and 05/01/2025. S1 to S3 stated that they provided or assisted R1 with showers/bathing but there were times when R1 refused to take showers/bath, and they admitted being neglectful to sign off on the shower skin sheet assessment form. 4 Out of 7 (S4 to S7) staff stated they did not help R1 with shower before. 3 Out of 7 staff (S1 - S3) stated when they assist residents with bathing or showers, they are required to sign the shower skin sheet assessment form. A copy of facility's staff showers skin assessment forms of R1 was obtained. On 05/05/2025, LPA conducted an interview with reporting party (RP). RP stated that on 04/27/2025, he/she noted that R1 had a skin and reddish color on chest. RP contested that if the staff were providing showers and assisting R1 with getting changed clothes during morning and bedtime, staff should have noted skin rash on R1's chest prior to 04/27/2025. RP notified staff that R1 had skin rash. Continue on LIC9099-C. Page 2 of 3. On 05/07/2025, LPA interviewed staff (S1 - S3) about R1's skin rash. 3 Out of 3 staff stated that they did not find skin rash prior to 4/26/2025 after it was reported to the facility by R1's family member (FM). Based on the interview with the facility staff, the facility staff were not aware of R1's rashes until R1's family notified the facility. Based on Cleveland Clinic Health Library Disease and Condition Information website, Skin Rashes can be red, inflamed, bumpy as well as dry, itchy or painful. The main cause is dermatitis, which is when skin reacts to allergens or irritants. Bacteria, viruses, allergens and conditions including eczema, hives, and psoriasis can be the source of skin rashes. There is no evidence that a skin rash is a direct result of poor hygiene itself. The department has investigated the above allegation. Based on the observations, records reviewed, and interviews conducted, 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 allegations did or did not occur. No deficiencies or citations noted at today’s compliant investigation visit. Exit interview conducted with ED. A copy of this report was provided to ED. Page 3 of 3.the state’s words, verbatim · CDSS document, Dec 30, 2025 · control 26-AS-20250429142323

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) conducted an unannounced annual inspection visit and met with Executive Director (ED) Meghian Geul. LPA reviewed 9 resident files and 8 staff files. License, Administrator Certificate, and personal rights posters were observed in the facility. LPA toured 1st floor to 4th floor of the building and the court yard. LPA toured the offices, Lobby, activity rooms, mail area, library, bistro area, theater, dining room, kitchen, restrooms, and fitness room. Room temperature was observed at 71 degree F. The temperature of the refrigerator was observed at 40 degree F and the temperature of the freezer was observed at -3 degree. Food storage can hold the 2 days of perishable food and 7 days of non-perishable food for the entire building. Fire extinguishers were on service on 8/12/2025. The facility was equipped with smoke and carbon monoxide detectors. carbon monoxide detectors were tested, and were working fine. Hot water was observed and checked at 108 degree F. Medication Room , laundry room and chemical storage room were observed locked. LPA tested the delay opening exit door of memory care unit. The alarm sounded when the exit door was pushed. The annual fire alarm system was tested by fire department on 3/25/2025. The emergency drill for the NOC shift was conducted on 9/21/25, for the 2nd shift was conducted on 9/25/25, and for the 1st shift was conducted on 10/31/2025. LPA observed 2 functioning elevator in the facility. Evacuation chairs were found at the stairs. No deficiency noted today. Exit interview was conducted with ED. The report was provided to ED for signature. A copy of the report was provided to ED.the state’s words, verbatim · CDSS document, Dec 12, 2025

Allegation investigated: Staff did not ensure that a resident's medication was inaccessible to another resident Staff did not ensure that a resident consumed medication as prescribed Staff did not prevent resident from wandering into another resident's room Staff did not notify responsible party regarding increase of facility fees

Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegation. LPA met with Administrator Meghian Geul. On June 13, 2024 the Department received a complaint alleging Staff did not ensure that a resident's medication was inaccessible to another resident / Staff did not ensure that a resident consumed medication as prescribed. On June 13, 2024, the Department interviewed Witness W1. W1 stated that two years ago (W1 stated he/she doesn't know the date), R1 took resident R2’s medication from his/her plate then consumed the medications. Page 1 Out of 5 Unfounded On June 20, 2024, LPA Simi Rai interviewed staff S1. S1 stated he/she does not recall if a resident consumed medications that were left on the table. S1 stated in Memory Care unit the protocol is to ensure the resident takes the medication and wait with them until they swallow the medication. S1 stated the med-tech doesn’t leave the medication lying around because the resident may forget to take the medication. On September 30, 2025, LPA Manuel Monter interviewed residents R3-R7. 5 Out of 5 residents (R3-R7) stated they handle their own medications, doesn’t need staff assistance and hasn’t had any issues with his/her medications. LPA Monter interviewed Staff S1-S3, S5. LPA also interviewed S4 & Current Memory Care Director, Norlynn Peterson. Staff S1-S3 & S5 stated staff gives residents their medications in person. Staff S1-S3,S5 stated medications are not given when residents are dinning. 5 Out of 5 staff (S1-S5) stated they haven’t seen or heard about residents taking each others medications. On October 6, 2025, LPA Manuel Monter interviewed Witness W1. W1 stated he/she doesn’t remember when the incident where R1 took R2’s medication occurred. W1 stated he/she was contacted by an unknown staff who informed him/her about this incident. On November 20, 2025, LPA Monter interviewed residents R2, R8-R11. 2 Out of 5 residents(R8, R9) interviewed stated they have not had any issues with receiving their medication. 2 Out of 5 residents(R8, R9) interviewed stated there hasn't been a time when they observed a resident taking other residents medication. 3 Out of 5 residents (R2, R10, R11) interviewed were unable to provide any relevant information due to neruocgonetive disorder. LPA interviewed staff S6-S9. 4 Out of 4 staff (S6-S9) stated medications are administered to residents in person, and the medtech will watch them take the medication before leaving. 4 Out of 4 staff (S6-S9) stated they haven't seen or heard about any instance of a resident taking another residents medication and consuming it. Page 2 Out of 5 On November 20, 2025, LPA Manuel Monter randomly audited 5 resident’s medications. LPA audited the medications by cross referencing the medication bottles/ containers and cross referencing with the Centrally Stored Medication Record and Medication Administration Record. No discrepancies were noted during review. The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. Staff did not prevent resident from wandering into another resident's room On June 13, 2024 the Department received a complaint alleging Staff did not prevent resident from wandering into another resident's room. On June 13, 2024, the Department interviewed Witness W1. W1 stated that in January 2023 (W1 doesn't know the date of this event) during dinner time, staff went looking for R1 and found the R1 lying on the floor in another resident's room. W1 stated he/she doesn't know how long R1 was inside of the other resident's room. On June 20, 2024, LPA Simi Rai interviewed Staff S1. S1 stated he/she does not recall when R1 was found lying on the floor of another resident's room. On September 30, 2025, LPA Manuel Monter interviewed residents R3-R7. 5 Out of 5 residents (R3-R7) stated they have not had any issues with other residents wandering into his/her apartment. LPA Monter interviewed Staff S1-S3, S5. LPA also interviewed S4 & Current Memory Care Director, Norlynn Peterson. 5 Out of 5 staff (S1-S5) interviewed stated if there residents who attempts to enter another resident’s bedroom, then staff will redirect them. On October 6, 2025, LPA Manuel Monter interviewed Witness W1. W1 stated regarding R1’s wandering, that he/she was informed by an unknown staff. W1 stated he/she doesn’t remember what room R1 entered or how long R1 was there. Page 3 Out of 5. On November 20, 2025, LPA Monter interviewed residents R2, R8-R11. 2 Out of 5 residents(R8, R9) interviewed stated they have not had any issues with other residents wandering or going into their bedroom and have not witnessed that occurring. 3 Out of 5 residents (R2, R10, R11) interviewed were unable to provide any relevant information due to neruocgonetive disorder. LPA interviewed staff S6-S9. 4 Out of 4 staff (S6-S9) stated there are residents who have the behavior of wandering and attempting to enter another residents bedroom. 4 Out of 4 staff (S6-S9) stated when this behavior is observed, staff will re-direct the resident. The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. Staff did not notify responsible party regarding increase of facility fees On June 13, 2024 the Department received a complaint alleging Staff did not notify responsible party regarding increase of facility fees. On June 13, 2024, the Department interviewed Witness W1. W1 stated in January 2024 (W1 stated he/she doesn't know the date) the facility increased R1’s facility fees from $7,500.00 to $9,000.00. W1 stated that prior to billing him/her, staff did not provide him/her with written notice. On September 30, 2025, LPA Manuel Monter interviewed Staff S4 & Current Memory Care Director, Norlynn Peterson. S4 stated when the facility notices residents now have a higher level of care, they will notify the staff. S4 stated they will then inform the staff of the updated care needs of said resident. S4 stated they will update the family regarding changes in care and the changes of cost as well. S4 stated ultimately the family has to agree. S4 stated if a residents level of care does go up, they naturally the residents cost of care would increase. Page 4 Out of 5. On October 6, 2025, LPA Monter interviewed Witness W1. W1 stated regarding the change in the fees, that he/she was informed by the staff that R1 had a higher level of care. W1 stated he/she was told the change of fees was for the level of care from level 1 to level 3. W1 did acknowledge that R1 was declining. W1 stated R1 began to show wandering behaviors when he/she moved into the facility. The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. Page 5 Out of 5. END OF REPORT.the state’s words, verbatim · CDSS document, Nov 20, 2025 · control 26-AS-20240613120601

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Manuel Monter arrived unannounced to deliver the results of a complaint investigation 26-AS-20240613120601. During the complaint investigation, a case management deficiencies visit was conducted due to violations discovered during the investigation process. LPA met with Administrator Meghian Geul. On September 30, 2025 the Department requested copies of R1’s Admission Agreement, documentation showing the facility notified R1’s responsible party of the rate increases. As of November 20, 2025, LPA has not been provided these requested documents to review and create copies. On November 20, 2025, LPA interviewed ADM Meghian Geul. LPA asked ADM if she can provide the requested documents to review. ADM stated R1 moved away from the facility on June 16, 2024. ADM stated the only documentation the facility has for R1 is his/her physicians report, care plan, and assessment Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with administrator Meghian Geul and a copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Nov 20, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(e) · Plan of correction due date: Nov 27, 2025

87506 Resident Records (e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requirement was not met as evidenced by: During the investigation, LPA requested to review documentation for R1, who moved from the facility on 06/16/2024. ADM stated the only documentation the facility has for R1 is his/her physicians report, care plan, and assessment.the state’s words, verbatim · CDSS document, Nov 20, 2025

Plan of correction: ADM stated she will send a letter of understanding regarding the regulation and the importance of ensuring residents records are retained for a minimum of 3 years. ADM stated she will submit the plan of correction by POC due date, November 27, 2025. (Continue) This poses/posed a potential health, safety or personal rights risk to persons in care.

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

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced Case Management to conduct a Non-Compliance Plan Quarterly Visit and met with Administrator (ADM) Meghian Geul. The purpose of the visit is to ensure the facility is adhering to the Compliance Plan submitted to Community Care Licensing (CCL) after an informal meeting held on 04/26/2024. LPA toured the memory care unit and tested the 3 exit doors in the memory care unit with ADM. The 3 exit doors made auditory sound when pressed and needs to enter the correct code to open. LPA tested the gate of the courtyard of memory care unit. The gate needs to enter correct code to open. LPA toured Med room of memory care unit. The Med room was observed locked and two Med Carts were observed in the Med Room. LPA reviewed staff in-service training log in July 2025 - October 2025 including but not limited to on topics : Medication error prevention, Resident right to privacy, reporting change in condition, reporting requirement and Elopement drill training. The case management of inspections will be conducted every 3 months for 2 years. No citation noted today. Exit interview was conducted with ADM. The report was provided to ADM for review and for signature. A copy of the report was provided to ADM.the state’s words, verbatim · CDSS document, Nov 5, 2025

Allegation investigated: Staff are not following emergency disaster plan procedures

Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegation. LPA met with Administrator Meghian Geul. On June 12, 2024 the Department received a complaint alleging Staff are not following emergency disaster plan procedures. On June 12 and 13, 2024, the Department interviewed witness W1. W1 stated he/she was called at 10:50pm because his/her family member can’t reach anyone to have his/her apartment’s power back on. W1 stated he/she was informed the hallways light were on but when his/her family member calls the front desk, there is no answer. W1 stated a nurse eventually showed up and provided some information to his/her family member around 11:00pm. Page 1 Out of 3. Unfounded On June 12, 2025, the Department interviewed Administrator (ADM) Gregory Becker. ADM stated the power outage was unplanned, from PG&E. ADM stated once the power went out, managers were notified and staff on duty. ADM stated the safety of residents was the highest priority, while most of the residents were already asleep at the time of the outage. ADM stated in memory care they did a 15 minute checks and head counts on all residents throughout the power outage. ADM stated for assisted living residents, they checked on residents to see how they were doing or needed anything. ADM stated the residents did not complain about any issue or discomfort. ADM stated staff members were posted on each floor of the community to be eye and ears for the safety of residents. ADM stated they have back up generators that powers hallways on each floor, refrigerator and freezer, which was working properly. ADM stated there was 12 staff on duty at the time of the power outage. On June 12, 2025, the Department received an incident report regarding the power outage. The incident report stated, on June 11, 2024, the power went out the community around 9:30pm. The incident report states the power outage was due to PG&E, and the power came back on June 12, 2024 at 3:45pm. On September 30, 2025, LPA Manuel Monter interviewed residents R1-R5. Residents, 4 Out of 5 residents interviewed (R1-R4) stated they don't remember the power outage that occurred on June 11 & 12, 2024. R5 stated he/she remembers when the power outage occurred on June 11 and 12, 2024. R5 stated staff did come to check on him/her, but doesn't remember how many times that night. LPA interviewed staff S1-S5. Staff S1 and S3 stated they were working on June 11 when the power outage occurred at the facility. Both staff (S1 and S3) stated they did health and safety checks on the residents every 15-30 minutes, while the power was out. Staff S2, S4 and S5 stated they were not working when the power went out on June 11 and 12, 2024. Based on a review, the facility has documented for June 11, 2024 and June 12, 2024, checks for memory care residents at the following times: 10pm, 11pm, 12:15am, 1:30am, 2:30am. Page 2 Out of 3. The Department reviewed the facility’s Power Failure Procedures. The procedures includes the following but not limited to: Reassure residents and to accommodate for call buttons that may be inoperable during a power failure, direct care staff will preform a check on residents assigned to them every 15 minutes until power is restored. Based on a review of PG&E’s Outage status tracker webpage, the facility outage was first reported on June 11, 2024, at 9:28pm. The power was restored on June 13, 2024, at 3:26pm. 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, Sep 30, 2025 · control 26-AS-20240612114650

Type of visit: Case Management - Other

On 09/04/25 Licensing Program Analyst (LPA) Marcela Yanez and Licensing Program Manager (LPM) conducted an unannounced complaint investigation visit to amend the complaint received on 10/17/24 (26-AS-20241017082303) and met with Executive Director (ED) Meghian Geul and announced the purpose of the visit. During visit LPA interviewed staff and obtained copies of 2 resident files including but not limited to Admissions agreement, move intake form, refund requests and identification and emergency information, addendum admissions agreement, Account ledger, LPM and LPA discussed pending complaints of 06/13/24 (26-AS-20240613120601) and 06/12/25 (26-AS-20240612114650) LPM requested copy of LIC 500 and discussed with ED that the LIC 500 needs to be updated and current list of staff. LPA determined that the above allegations require further investigation. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Executive Director Meghian Geul and a copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 4, 2025

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

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced Case Management to conduct a Non-Compliance Plan Quarterly Visit and met with Administrator (ADM) Meghian Geul. The purpose of the visit is to ensure the facility is adhering to the Compliance Plan submitted to Community Care Licensing (CCL) after an informal meeting held on 04/26/2024. LPA toured the memory care unit and tested the delayed egress doors in the memory care unit with ADM. The delayed egress doors made an auditory sound when pressed and needs to press the correct code to open. LPA toured the exit door of the garage and the main entrance with ADM. LPA reviewed the resident check-out and check-in log for June and July 2025. LPA reviewed the memory care unit exit door checking log for April, May, June, and July 2025. LPA reviewed staff elopement training log for April, May, and June 2025. LPA reviewed staff in-service training log in April 2025 - June 2025 including but not limited to on topics : Medication error prevention, Resident right to privacy, reporting change in condition, reporting requirement. No citation noted today. Exit interview was conducted with ADM. The report was provided to ADM for review and for signature. A copy of the report was provided to ADM.the state’s words, verbatim · CDSS document, Jul 3, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Marcela Yanez arrived unannounced to conduct a case management- other to amend a complaint investigation report (LIC9099) to add additional information to the report. LPA announced the purpose of the visit and met with Assisted Living Director Jmy Ramos . On 03/04/25 the department received a complaint regarding the facility Ivy Park at Milpitas. On 03/12/25 the Department conducted an initial investigation. On 05/23/25 the department concluded its investigation and LPA conducted a complaint investigation visit to deliver the findings due to the report needing additional information to support findings the complaint was not closed. On 06/12/25, LPA conducted a visit to amend the report. The findings of the allegations remain unsubstantiated. No deficiencies cited during today's visit. This report was reviewed with Jmy Ramos, Assisted Living Director and a copy of the signed report was provided.the state’s words, verbatim · CDSS document, Jun 12, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced case management visit and met with Executive Director (ED) Meghian Geul. On 6/4/2025, the Department received an incident report that on 6/2/2025 around 7:20PM a memory care unit resident R1 was found outside the building of the facility. A independent living resident R2 escorted R1 back to the facility. A Med Tech (MT) was notified notified, MT escorted R1 back to memory care unit. R1 was observed without injuries. LPA interviewed Executive Director (ED), 2 resident (R1,R2), 4 staff (S1 - S4). LPA obtained R1's physician report and appraisal needs and service plan. LPA toured the memory care unit, two court yards, main entrance, and facility garage with ED. This case needs further investigation. Exit interview was conducted with ED. The report was provided to ED for review and signature. A copy of the report was provided to ED.the state’s words, verbatim · CDSS document, Jun 5, 2025

Allegation investigated: Staff does not ensure facility has hot water.

Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegation. LPA met with Administrator Meghian Geul On May 21, 2025 the Department received a complaint alleging Staff does not ensure facility has hot water. On May 19, 2025, the Department received an incident report from the facility. The incident report stated, "on May 16, 2025 (Friday), around 10am this morning residents reported no hot water when they took a shower. The water heater was checked and we found both water heaters were not working.... Water heater will be repaired tomorrow, Saturday May 17, 2025. Page 1 Out of 3. Substantiated On May 19, 2025, LPA Manuel Monter spoke to ADM. ADM stated the water heater went out and the only water heater in the facility that was working was in the kitchen. ADM stated the hot water was out Friday mid morning and on 5/19/2025, the water heaters have been fixed. LPA asked ADM if there was any plan/alternative to give residents hot water to bathe during the time period where the water heater wasn’t working. ADM stated No. On May 21, 2025, LPA Manuel Monter interviewed residents R1-R5. Residents R2 – R5 stated the hot water in the facility stopped working on Friday, 5/16/25. R1 stated the hot water at the facility stopped working on Thursday, 5/15/25. R1 stated he/she was informed the water heater was repaired on two different dates, but the water heater was not repaired. All residents interviewed stated the water heater was repaired on 5/20/2025. All residents interviewed stated the facility did not provide any other options/ alternatives for resident to shower/ bathe with hot water, while the water heater was in repair. On May 21 and 30, 2025 LPA Monter interviewed staff S1-S4. S1 stated the hot water was not working in the facility back last Friday, 5/16/25. S1 stated the water was fixed, then it was out again, then fixed again. S1 the plumber last came in on Tuesday. S2 stated that hot water was out on Friday, May 16, 2025. S2 stated the hot water was working at the facility on 5/20/2025. Staff S3 stated the hot water was not working on Friday evening. Staff S4 stated he/she was informed the hot water was not working on May 16, 2025. S4 stated he/she was informed the water heater had been fixed on May 17, 2025. S4 stated he/she was not working from the 18-26th of may, and doesn't know whole scope of the event. All staff interviewed stated the facility did not provide any other options/ alternatives for resident to shower/ bathe with hot water, while the water heater was in repair. Page 2 Out of 3 On May 22, 2025, LPA Manuel Monter interviewed witness W1. W1 stated he/she responded to the water heater at Ivy Park Milpitas not functioning. W1 stated he/she was called to investigate the cause of a water heater not working at approximately 2:22 PM May 20, 2025. W1 stated he/she arrived at Ivy Park at approximately 2:24 PM to investigate and was shown the water heater. W1 stated the water heater was at 89 degrees when he/she arrived. W1 stated he/she diagnosed the problem and went to work up an estimate. W1 stated based on the part of the water heater that was in disrepair, there wasn’t anything the facility could do to prevent it from failing. W1 stated it a part that will eventually over time be in disrepair. W1 stated because this was an uncommon part, he/she had to contact all local providers in a 30 mile radius. W1 stated he/she located and acquired the materials necessary to restore hot water and returned to Ivy Park Milpitas at 3:34PM May 20, 2025. W1 stated he/she restored hot water at approximately 4:44PM. Based on interviews conducted and documents reviewed, although the facility did hire a plumbing company to address the water heater that was in disrepair, the facility did not implement a plan any other options/ alternatives for resident to shower/ bathe with hot water, while the water heater was in repair. Based on interviews with facility ADM, the water heater was in disrepair from 5/16/2025- 5/20/2025. Based on interviews and documents review the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED. Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 9099-D. This report was reviewed with Administrator Meghian Geul and a copy of the report was provided. Appeal Rights was provided. Page 3 Out of 3.the state’s words, verbatim · CDSS document, May 30, 2025 · control 26-AS-20250521085417

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: May 31, 2025

87468.1 Personal Rights of Residents in All Facilities (a) (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by; Based on interviews & records reviewed, the facility did not ensure safe, healthful and comfortable accommodations, by not providing access to hot water during the time period where the water heater was malfunctioning.the state’s words, verbatim · CDSS document, May 30, 2025

Plan of correction: ADM stated the water heater are now working. ADM stated she will send a letter of understanding regarding the regulation. ADM stated she will send to LPA by POC date. (Cont) This poses an immediate health, safety and personal rights risk to residents in care.

Allegation investigated: Staff are serving food that is not of quality to residents in care. Staff are not following a resident's admission agreement. Staff did not ensure that activities are provided for residents in care.

*Amended to add document review for activity director training log* On May 23, 2025 Licensing Program Analyst (LPA) Marcela Yanez conducted an unannounced complaint investigation visit to deliver findings on the above allegations. LPA met with Meghian Geul, Administrator. On March 4, 2025 the department received a complaint with the above allegations. On March 12, 2025 LPA Yanez and LPA Jain interviewed Staff S1-S3, Interim Director (ID) and Residents (R1-R7). 7 out of 7 residents stated the food is ok but sometimes it is cold or not hot enough and the food is better on the weekend and occasionally the soup is too hot. 3 Out of 3 staff stated that the food served to residents is checked with a thermometer prior to serving. on May 21,2025 LPA Monter interviewed 5 staff. The food does not meet the food quality standard based on the right temperature food is not served. 2 out of 3 staff stated that when food is returned cold to the kitchen the food is replated and not reheated. Unsubstantiated On occasion the facility Chef engages residents in conversation to sample food on the menu and provided their opinions and suggestions. LPA toured the facilities kitchen and dining area. LPA observed residents in the dining area and observed food served on the menu was of good quality and nutritious. On March 12, 2025, LPAs Yanez and Jain interviewed 7 residents (R1-R7) 1 out of 7 stated he/she missed two dental appointments due to not having a driver and stated that the Activity Director was providing rides, but went on leave. Licensing Program Analysts (LPAs) Marcela Yanez and Kiran Jain interviewed 7 residents (R1-R7) and Interim Director regarding the facility driver and transportation services as part of the basic service as stipulated on the resident’s admission agreement. ID stated that the facility driver had resigned in January 2025 and tried to make arrangement with sister facilities if a driver can be provided but was unsuccessful. The facility recently hired an individual to start the week of March 9, 2025, but the individual did not show up for work. The facility is actively seeking for a qualified driver that has the necessary skill and proper license to drive the facility’s van which requires a Class B License, ID stated that the facility is arranging transportation by using third party vendor rides for the residents such as Uber or Lyft. The residents could use their own app to schedule transportation, and facility reimburses the resident for the fee charged or the front desk schedules the ride for residents. LPAs Yanez and Jain continued to interview Interim director. ID stated that the facility Activity Director is out on leave since February 2025 and stated, the direct support staff are filling in for the Activity Director. However, Activity Coordinator called out several times during the last month and the Staff filling in for the activity director and coordinator is a direct support staff. **** Amended statement to include training log was reviewed**** During investigation LPA Yanez reviewed Training log for staff conducting activities and verified staff had been trained and experience in administering and directing activities to residents. The Direct Support Staff has been promoted to Activity director as of April 27, 2025. Kitchen staff records were also reviewed and staff had training in food handling and food preparation. LPAs interviewed 7 residents (R1-R7). 7 out of 7 stated the activities does not exist or not posted on the schedule. 7 Out of 7 stated that the person conducting the activities was not experienced, and did not have the correct supplies for the activities. LPA Yanez observed a meeting conducted by ID with approximately 20 residents in attendance. The meeting is regarding the activities not being provided according to the posted schedule and activities that the residents prefer. The facility conducted a survey among the residents and gathered suggestions for activities that would interest all the residents. Based on document reviews, interviews and observations the department has completed its investigation and found that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the above allegations are unsubstantiated. No deficiencies are being cited during today’s visit based on California Code of Regulations Title 22. An exit interview was conducted with Administrator Meghian Geul and a copy of the report was provided.the state’s words, verbatim · CDSS document, May 23, 2025 · control 26-AS-20250304120229

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced case management visit and met with Executive Director (ED) Meghian Geul. The purpose of today's visit is to follow up with the case management visit conducted on 5/7/2025. On 5/2/20254, the Department received an incident report from the facility that an incident between resident R1 and resident R2 occurred on 4/29/2025 at the facility. On 5/7/2025, LPA interviewed ED, 2 residents (R1, R2) and 2 witness staff (S1, S2). LPA requested physician reports and service plans of resident R1 and R2. Based on the interview and review of incident report, on 4/29/2025, around 2:00PM, in the activity room, resident R1 was walking by the chair which resident R2 was sitting on. R2 suddenly pushed R1 with no reason and R1 fell on the ground. Caregivers and Med Tech separated R1 and R2 immediately. Caregiver S1 was on site to help residents during the activity and staff S2 conducted the activity in the activity room. Both S1 and S2 stated there was no altercation between R1 and R2 prior the incident. This is the first incident between R1 and R2. The facility updated the care plans of R1 and R2. Staff training of abuse prevention and managing aggressive behavior has been provided to staff on 5/2/2025.. Continue on LIC809-C. Page 1 of 2. Based on the review of physician reports of R1 and R2, R1 has no aggressive behavior and R2 has verbal aggressive behavior. No citation was issued today. Exit interview was conducted with ED. The report was provided to ED for review and signature. A copy of the report was provided to ED.the state’s words, verbatim · CDSS document, May 23, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Manuel Monter arrived unannounced to conduct a case management visit to follow up on a medication error. LPA met with and stated the purpose of the visit. On May 20, 2025 the Department received an Incident Report for a medication error of Resident R1 that occurred on May 13, 2025. The incident report states: "on 5/13/25, during medication reconciliation, it was identified that the resident continued to receive Medication M1, 50 mg despite a physicians order on 4/23/25 to discontinue the 50mg does and initiate M1 25 mg instead. From 4/23/25 to 5/13/25, the resident erroneously continued to receive the 50 mg dose. this discrepancy was identified by the hospice nurse. " On May 20, 2025, LPA Marrufo interviewed ADM. ADM stated R1's medication was changed to half dose instead of a full one and they did not catch that the order was changed. ADM stated an in-service was provided to staff. On May 21, 2025, LPA Monter interviewed Resident Care Coordinator. (RCC). RCC stated the residents physicians order on 4/23/25, instructed a change to the residents dosage. RCC stated the med techs are supposed to send this update to the pharmacy to update those changes. RCC stated this issue was noticed by the hospice nurse on May 13, and update that same day. A deficiency is being issued during today's visit per California Code of Regulations, Title 22, see LIC809D. An exit interview was conducted with Administrator Meghian Geul and a copy of this report was provided. Appeal rights were also provided.the state’s words, verbatim · CDSS document, May 21, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: May 22, 2025

87411 Personnel Requirements - General (a) Facility personnel shall at all times be...competent to provide the services necessary to meet resident needs This requirement was not met as evidenced by Based on investigation, From 4/23/25 to 5/13/25, resident R1 erroneously continued to receive the 50 mg dose for medication M1. This poses an immediate health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 21, 2025

Plan of correction: Administrator stated the facility conducted an in-service for staff on medication training, on May 17, 2025 ADM provided documentation of in-service training conducted on May 17, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) conducted an unannounced case management - incident visit and met with Executive Director (ED) Meghian Geul. On 4/2/20254, the Department received an incident report from the facility that an incident occurred on 4/29/2025 at the facility. On 4/29/2025 around 2:00PM, resident R1 was walking in the memory care unit living room by resident R2's chair, R2 pushed resident R1 without reason. R1 fell on the ground. STaff called 911 and R1 was sent to hospital. LPA interviewed ED, 2 residents (R1, R2) and 2 witness staff (S1, S2). LPA requested physician reports and service plans of resident R1 and R2. This case needs further investigation. Exit interview was conducted with ED. The report was provided to ED for review and signature. A copy of the report was provided to ED.the state’s words, verbatim · CDSS document, May 7, 2025

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

Licensing Program Analyst (LPA) Marcela Yanez conducted an unannounced Case Management visit to conduct a Non-Compliance Plan Quarterly Visit and met with Meghian Geul, Administrator. LPA announced the purpose of the visit. The purpose of the visit is to ensure the facility is adhering to the Compliance Plan submitted to Community Care Licensing (CCL) after an informal meeting held on 04/26/2024. LPA requested the following documents for in-service training for staff between 12/01/24 to 04/01/25. Which included but not limited to: Elopement, Working with hospice, emergency drill, Medication assistance, Cognitive issues, emergency drill, PPE and hand washing, preventing recognizing and reporting abuse, elopement protocol, back to basic medication assistance, medication error policy, miss or refused medication policy, the six rights, controlled medication, medication storage, change of condition/scabies/skin reporting, medical emergencies calling 911, elopement response time(shift report), shower skin sheet, medication error prevention, security door checklist, shift report documentation, hospice nursing service, ADL competency, controlled medication, pharmacy profiling, activity engagement, behavioral expressions, foley catheter empty bag, security door checklist for door shift change, meal roster, shower sheets, temperature logs, safe in room, dementia behaviors abuse prevention, what is hospice, and staff crossover. LPA toured the memory care unit and tested egress doors and the doors made an auditory sound when opened, all exit doors to courtyard in memory care have a auditory alarm when opened that needs a code to reset. No deficiencies cited per California Code of Regulations, Title 22. This report was reviewed with Meghian Geul and a copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 11, 2025

Allegation investigated: Staff do not provide adequate supervision resulting in residents sustaining falls

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation finding and met with Business Office Director (BOD) Mimi Co. On 6/10/2024, the Department received a complaint with the allegation that staff do not provide adequate supervision resulting in residents sustaining falls. On 6/20/2024, the Department conducted an initial investigation visit. LPA interviewed 3 staff and requested resident's physician report, appraisal needs and service plan. Continue on LIC9099-C. Page 1 of 3. Unsubstantiated Staff do not ensure facility is cleaned and sanitized: The allegation is that resident R1's bedroom was observed on the floor, and caregivers were unable to access the cleaning supplies room to obtain the cleaning supplies. On 6/16/2024, LPA interviewed R1's family member (FM). FM stated on 5/24/2024, he/she visited R1. A home care nurse was checking R1 blood sugar. The home care nurse told FM that he/she saw feces on the floor in R1's room when he/she entered R1's room. FM stated he/she saw a staff was cleaning R1's room and changed R1's clothes. FM stated he/she did not see feces on the floor. On 6/20/2024, LPA interviewed a Med Tech S1. S1 stated caregivers do the room cleaning more often than housekeepers, caregivers do the basic cleaning every shift. S1 stated staff have access to the cleaning supplies room and the facility has sufficient cleaning supplies. LPA interviewed caregiver S2. S2 stated housekeepers do room deep cleaning and the caregivers do the basic cleaning. S2 stated the chemical cleaning supplies are locked in the cleaning supplies room and housekeepers have the access to the cleaning room. S2 stated caregivers are given disinfectant wipes S2 stated resident R1 was found with Bowel Movement (BM) in pants several times. R1 was given briefs, but R1 does not like it because it is uncomfortable. S2 stated R1 has laundry twice a day and showers as needed. On 7/12/2024, LPA interviewed S4. S4 stated the facility cleans resident rooms twice per week. S4 stated if caregivers find BM, they will clean first and notify housekeepers to do deep cleaning. LPA interviewed staff S3. S3 stated resident rooms are cleaned every other day. S3 stated if caregivers find BM on the floor of resident room, they will clean it up and housekeepers will give additional deep clean. LPA interviewed Med Tech S1. S1 stated caregivers clean resident rooms every day. S1 stated if BM was found in resident room, caregivers will clean it up. LPA interviewed caregiver S5. S5 stated if caregivers find BM on the floor in resident room, they will clean it up and notify housekeepers to do deep clean. S5 stated one day, R1 had BM in the pants when home care nurse came. S5 stated he/she cleaned it up, gave shower to R1 and changed R1's clothes. Continue on LIC9099-C. Page 2 of 3. LPA toured and checked 16 resident rooms, LPA did not see any BM or trash on the floor of the resident rooms. Based on the review of R1's service plan dated 3/16/2024, R1 was at the beginning stage of incontinence. 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 complaint investigation visit. Exit interview conducted with Business Office Director (BOD) Mimi Co. This report was provided to review and for signature. A copy of this report was provided to BOD. Staff do not provide adequate supervision resulting in residents sustaining falls: The allegation is that resident R1 had multiple falls and was sent to Emergency room frequently. On 6/16/2024, LPA interviewed resident R1's family member (FM). FM stated on 6/1/2024, he/she received a phone call from a Med Tech that R1 had a fall when he/she was driving to the facility to visit R1. FM stated R1 was not sent to hospital emergency room for R1's fall on 6/1/2024. FM stated R1 had two falls and was sent to emergency room in 2023. FM stated he/she cannot remember the dates of R1's fall in 2023. FM stated maybe around in July 2023 and October 2023. On 6/20/2024, LPA interviewed Med Tech S1. S1 stated residents were hourly checked by staff. S1 stated caregivers report to Med Tech if they found residents were unusual. S1 stated resident R1 is usually in the activity room or TV room during waking hours. S1 stated R1 had fall before but R1 does not have frequent falls. LPA interviewed caregiver S2. S2 stated resident R1 should use walker but sometimes R1 did not use walker. S2 stated staff picked up R1 with R1's walker when staff to place R1 in activity room or TV room. S2 stated R1 likes to get up by self and walk to the places faster. S2 stated R1 seldom told caregivers what he/she needs, such as need to go to restroom. On 7/12/2024, LPA interviewed caregiver S3. S3 stated there are 3 caregivers for memory care unit for AM shift and for PM shift. S3 stated caregivers need to keep eyes on fall risk residents and closely monitoring them. S3 stated he/she does not know any resident fell and was sent to hospital recent 3 months. LPA interviewed caregiver S4. S4 stated caregivers need to take care of the residents who are fall risk. S4 stated caregivers need to assistance those who are fall risk to/from their rooms to prevent falls. LPA interviewed caregiver S5. S5 stated residents are checked every hour, caregivers follow residents who are fall risk when they are ambulating. S5 stated R1 had a fall several months ago and a Med Tech helped R1 up. The Med Tech notified R1's family member immediately. S5 was unsure if R1 was sent to hospital or not. Continue on LIC9099-C. Page 2 of 3. Based on review of R1's incident reports, there was no incident report that R1 was sent to hospital emergency room due to fall in July 2023 or in October 2023. Based on the review of R1's physician report dated 4/28/2024, R1 uses walker/Cane, and should be escorted by staff due to physical impairment. Based on the review of R1's Service plan dated 3/16/2024, R1 needs to use walker or cane, R1 not always use walker/cane, and R1 walks fast. R1 needs reminders to not get up abruptly. Based on the review of R1's progress notes, on 6/1/2024, R1 has a fall on 6/1/2024, R1 was not sent hospital. At the same day, R1 was picked up by Family Member and went out for lunch. Based on the interview and records reviewed, no evidence to indicate that staff do not provide adequate supervision resulting in R1 sustaining multiple falls and was sent to emergency room frequently. 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 BOD. A copy of this report was provided to BOD. Page 3 of 3.the state’s words, verbatim · CDSS document, Jan 7, 2025 · control 26-AS-20240610145129

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Marcela Yanez and Manuel Monter conducted an unannounced Required 1 Year visit and met with Resident Service Director, Jmy Ramos, LPAs stated the purpose of the visit. LPAs toured the facility inside and out, which include 4 floors . LPAs randomly inspected the following, but not limited to resident bedrooms: 450,471,485, 322,360, 367, 280, 270, 209. LPAs randomly tested the resident bathroom on each floor water temperature with thermometer and measured range from 106 to 112 degrees F. LPAs toured the Memory Care unit inside and out. LPAs randomly inspected the following, but not limited to resident bedrooms: 105, 103, 125 LPAs randomly tested bathroom water temperature with thermometer and measured to range from 110 to 112 degrees F. LPAs tested delayed egress doors which activated auditory sound when pressed. LPAs also inspected the dining area and kitchen of the facility. LPAs observed perishable food supply of at least two days and a non-perishable food supply of at least seven days. No obstructions were noted during tour. LPA toured the outside area and found the exits to be clear of obstructions. LPAs observed fire extinguisher was last serviced on 04/22/2024. LPA reviewed Fire and Earthquake log which stated the last drill was conducted on 11/25/24. The Sprinkler system was last serviced on 12/06/2024. Page 1 of 2 LPA reviewed resident records for 5 residents and reviewed CSMDR and found to be complete. LPA reviewed 5 staff records and found them to be complete. LPA provided Resident Service Director with a flyer "Important updates to Dementia Care & Miscellaneous Changes, Effective January 1, 2025." No deficiency were cited as per California Code of Regulations Title 22. This report was reviewed with Resident Service Director, Jmy Ramos and a copy of this report. Page 2 Out of 2. END OF REPORTthe state’s words, verbatim · CDSS document, Dec 28, 2024

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

Licensing Program Analyst (LPA) Manuel Monter and Marcela Yanez conducted an unannounced Case Management to conduct a Non-Compliance Plan Quarterly Visit and met with Resident Service Director Jmy Ramos. Administrator was not present at the facility and busy at the time of the visit. The purpose of the visit is to ensure the facility is adhering to the Compliance Plan submitted to Community Care Licensing (CCL) after an informal meeting held on 04/26/2024. LPA's toured the memory care unit and tested the delayed egress doors in the memory care unit. The delayed egress doors made an auditory sound when pressed. LPA Monter reviewed staff in-service training summaries conducted from 08/01/2024 - 12/01/2024 on topics included but not limited to: Resident right to privacy, reporting abuse, Dementia care: working with hospice, theft and loss, & elopement. No deficiencies cited per California Code of Regulations, Title 22. This report was reviewed with Resident Service Director Jmy Ramos and a copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 28, 2024

Allegation investigated: Facility did not notify POA that the resident will need higher level of care resulting in increase rate.

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the finding of the above allegation. LPA met with Executive Director, Gregory Becker. On 05/21/2024, the Department received the complaint. On 05/29/2024, the initial complaint investigation was conducted. The following documents were obtained to include the compass rose resident roster, memory care schedule for May 2024, illness tracking form for GI Illness/Norovirus/Other illness, and resident (R1)’s physician’s report, service plan, admission agreement, account statement ledger, and other correspondences. It was alleged that the facility did not notify resident (R1)’s power of attorney (POA) that resident (R1) will need higher level of care resulting in an increased rate. See LIC9099-C. Substantiated The review of R1’s account ledger shows that R1’s level of care cost increased from $1,325 to $2,450 in March 2024. This new level of care cost was carried through until May 2024. In June 2024, R1's care cost decreased to $1,950. On 05/29/2024, 3 staff members were interviewed. Based on staff interview, it was stated that because R1’s assessment was at the 6 month time-frame, a re-assessment was completed due to that reason and not because R1 needed a different level of care or there was a change in condition. The review of R1’s service plan dated 05/14/2024, shows that R1’s level of care decreased from a care level 5 (05/20/2023) to a care level 3 (05/14/2024). The facility was unable to produce documentation to reflect an updated care plan showing the care increase between February 2024 – March 2024. Based on interview with staff (S4), the level of care cost is reflected from the assessments which are discussed with the resident’s authorized representative and director in memory care. If a resident’s level of care is being increased, S4 would mail a letter to the resident’s POA regarding the notice of the increased level of care cost. Based on the admission agreement between the facility and R1, it stated that upon a change in the care needs that will result in increase points the facility will provide a written notice to the resident or representative, if any, within two business days of providing service at the new level of care that results in a rate increase. It states that the notice will include a detailed explanation of the additional services provided and charges associated with such. Based on interview with the ED, record review and observation the facility was unable to produce any documentation that was provided to R1’s POA regarding the increase of level of care cost to include an updated care plan and written notice. Based on staff interview, the staff was unable to provide an explanation as to why R1’s care cost increased in March 2024. The Department has investigated the above allegation. Based on interview, record review and observation the preponderance of evidence standard has been met, therefore, the above allegation is substantiated. A deficiency is being cited per California Code of Regulations, Title 22. See LIC9099-D. This report was reviewed with the Executive Director, Gregory Becker and a copy of the report and appeal rights were provided. The RP provided a photograph of a memo that was posted at the memory care unit dated 05/18/2024, which provided as a notification to the residents and families of a flu like bug that was going around causing residents to be sick. The memo advised to refrain from visiting at this time and to continue washing hands often and hand sanitize. Based on interview with staff (S3), family members of those residents who were affected by scabies were contacted. A memo was also posted in the memory care unit as part of the notification. Residents who were itching were immediately treated and their family member were also notified. It was stated that they only notify family who were affected by the scabies. It was stated that they did not notify every family member, but they did post a memo in the memory care unit. On 05/29/2024, the Executive Director (ED) was interviewed. Based on interview, the ED states that they notify the community of potential concerns verbally and through a memo they post. Mass notifications were done only for COVID-19, however, not with the stomach flu. It was stated that they only notify the resident’s family if the resident was affected. Per the reporting party, a memo was posted in the memory care unit but no email was sent to the family members notifying family of the scabies outbreak. The review of the facility’s infection control policy and procedures dated in 2023 includes a checklist to notify residents and responsible parties which could be done by posting a sign at the entrance. In the facilities infection control plan, there is no indication of a mass email required to be sent to all residents and/or their responsible parties. It was alleged that R1’s physician prescribed R1 with an electric wheelchair, however the facility did not allow resident (R1) to use the electric wheelchair to help with R1’s mobility. Page 2 of 4. Based on interview with staff (S2), it was stated that in the past, R1 would get angry and would wheel him/herself towards people in his/her manual wheelchair. S2 stated that there would be times when R1 would try to run over staff in his/her manual wheelchair. On 05/29/2024, 8 staff members were interviewed. Based on staff interviews, the care staff denied observing R1 attempt to hurt staff or residents with his/her wheelchair. Staff stated that sometimes R1 would get upset, however, denied having aggressive or inappropriate behavior towards residents and staff with his/her wheelchair. Based on record review of R1’s physician’s report it indicates that R1 is confused/disoriented and has aggressive, wandering, and sundowning behaviors. The review of R1’s service plan dated May 2024 and signed in June 18, 2024 shows that R1 needs occasional support due to disruptive, aggressive, or socially inappropriate behaviors. R1’s care plan notes that at time R1 will lost his/her temper. Based on interview with staff (S2), R1 had been determined to be unsafe in an electric wheelchair in the memory care unit as there were concerns that R1 may hurt him/herself and others. It was alleged that the facility’s memory care unit is severely understaffed as there is only 3 caregivers in memory care, in which the ratio is 1 caregiver to 10 residents. It was alleged that due to the shortage of staff, residents care needs are being neglected as staff are not able to respond quick enough. For example, a resident’s responsible party asked staff for help to change R1, but the staff replied stating he/she couldn’t help because other residents had a bowel movement and also needed help. On 05/29/2024, 5 staff members in memory care were interviewed. Based on staff interview, it was stated that the facility’s memory care is understaffed and staff are overwhelmed. It was stated that the facility management reduced the staffing ratio from 4 caregivers to 3 caregivers, in which each caregiver is assigned about 10 residents to their group. Page 3 of 4. Staff stated that due to the reduction of staff, it’s affected the resident’s quality of care. Staff expressed the difficulty to attend to the residents when needed but because they work so hard they are able to take care of their needs where the residents are not neglected. On 05/29/2024, 3 staff from the management team was interviewed. Based on interview, 3 out of 3 staff denied the facility’s memory care unit being understaffed. It was stated that they divide the residents in groups based on their care and services. It was stated that they are not looking for more staff and more staff will be added if they get more residents and hospice residents. Staff stated that with the current resident census of 29 residents, their staffing is sufficient. The Department has investigated the above allegations. Based on interview, record review and observation the above allegations are unsubstantiated. An unsubstantiated finding indicates that although the allegations are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Executive Director, Gregory Becker and a copy of the report was provided. Page 4 of 4.the state’s words, verbatim · CDSS document, Dec 20, 2024 · control 26-AS-20240521185706

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87507(f) · Plan of correction due date: Dec 21, 2024

(f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement is not met as evidenced by: Based on interview, record review and observation the licensee did not comply with this section wherein the licensee did not provide R1's authorized representative with a written notice regarding the level of care increase prior to charging R1 the new care cost which poses an immediate health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 20, 2024

Plan of correction: Licensee will have a discussion with the home office and accountants regarding R1's ledger from March - May 2024 for possible credits back into R1's account. Licensee will provide an update to the Department regarding this concern. Licensee will submit an outline of their procedures regarding notification of level of care increase. Licensee will submit this POC to LPA Dolores via email by POC due date of 12/21/2024.

Type of visit: Case Management - Incident

Licensing Program Analysts (LPAs Manuel Monter & Marcella Tarin conducted an unannounced case management visit continuation in regards an incident report, which stated a resident had eloped from the facility. LPAs met with Administrator Gregory Becker. LPAs explained the purpose of the visit. On August 26, 2024, the Department received an incident report (LIC624) regarding a resident (referred as R1) who eloped from the facility. According to the report, on August 20, 2024, at 12:10am, during rounds staff (referred as S12) noted that resident R1 was not in his/her bedroom in the memory unit. Staff S11 and S12 conducted a census of all memory care residents to account for the whereabouts of R1. During the rounds, the local law enforcement (LLE) arrived with resident R1, who was found outside the facility. On August 19, 2024, at about 10:16pm Local Law Enforcement (LLE) responded to resident R1 being found nearby the Apartments complex (Apex). (Based on a google maps review of the location R1 was found, R1 was .5 miles away from the facility). At around 12:30am, R1 was brought back to the facility by LLE wherein staff stated they were unsure how he/she had left the facility. Based on a review of R1’s Elopement Risk Assessment, dated July 2, 2024, R1 has a history of elopement and has wandering behaviors. Based on a review of R1’s Physicians Report, dated July 2nd, 2024, R1 has a diagnosis of neurocognitive disorder. R1 also has wandering behaviors and cannot leave the facility unassisted. Page 1 Out of 2. On August 28, 2024, and September 16, 2024, the Department interviewed 13 staff (referred as S1-S13) and Memory Care Director (MCD). 11 Out of 13 staff interviewed stated R1 has had wandering and exit seeking behaviors since he/she moved into the facility. S1 stated R1 was in his/her group, for the PM shift, the day of the elopement. S1 stated the last time he/she saw R1 was at 8:15pm on August 19, 2024. S1 stated he/she did not perform a head count of all residents assigned to him/her because he/she was busy helping other residents. Staff S12 confirmed R1 was in his/her group of residents, for the night shift on August 19, 2024. S12 stated the PM shift had informed the shift, that all the residents were in bed, but did not conduct a head count at 10:00pm. On October 4, 2024, LPA Monter and Tarin, interviewed MCD. MCD confirmed that staff need to conduct a head count of residents in the memory care unit at the beginning of their shift and end of their shift. Based on interviews, R1 was last seen by S1 at 8:15pm, on August 19, 2024. R1 was not found during head count, at 12:10am, on August 20, 2024. Based on interview, the facility staff did not preform their duties and responsibilities by not conducting a head count/welfare check for all residents in memory care between the changes in shift, PM and NOC, at 10pm to meet the care & supervision needs of the residents in memory care unit. As a result, the department issued an immediate civil penalty of $1,000 for a repeat violation the absence of supervision, which resulted in R1 eloping from the facility. Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D. This report was reviewed with Administrator Gregory Becker and a copy of the report was provided. Appeal Rights was provided. Page 2 Out of 2. END OF REPORTthe state’s words, verbatim · CDSS document, Oct 4, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Oct 7, 2024

87468.1 Personal Rights: (a)(2) Each resident shall be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: Based on interview and record review, on August 19, 2024, R1 with a neurocognitive disorder left the memory care unit unassisted and was found by law enforcement 0.5 miles away from the facility. This poses an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 4, 2024

Plan of correction: Administrator stated he will submit our plan of action regarding elopements. ADM stated he will update R1's apprisal. ADM stated he will send a letter of understanding regarding the regulation. ADM stated he will send the Plan of Action by POC date October 7, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR87468.2(a)(4) · Plan of correction due date: Oct 7, 2024

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)(4)To care, supervision... delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on interview, the staff perform their duties & responsibilities by not conducting a head count/welfare check for all residents in memory care between the changes in shift, PM & NOC, at 10pm to meet the care & supervision needs of the residents. This posed an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 4, 2024

Plan of correction: Administrator stated he/she will submit a plan of corrections regarding staffing in the memory care unit. ADM stated he will send the Plan of Action by POC date October 7, 2024.

Allegation investigated: Resident did not feel safe and comfortable in facility environment Facility not providing transportation to medical appointments Staff neglected resident’s hygiene

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the finding of the above allegations. LPA met with Executive Director, Gregory Becker. On 05/17/2022, the Department received the complaint. On 05/26/2022, the initial complaint investigation was conducted. Documents were obtained throughout the investigation to include resident (R1)’s admission agreenement, incident reports, physician’s reports, medical records, advance health care directive, power of attorney (POA) documents, service plan, preplacement appraisal, personal rights form, and resident sign in / sign out sheets. PAGE 1 OF 4. Unsubstantiated It was alleged that resident (R1) did not feel safe and comfortable in the facility’s environment because R1 did not have a telephone to receive calls. On 05/26/2022, R1 was interviewed. Based on interview, R1 stated to have felt isolated because R1 did not have a telephone to receive calls. R1 did not provide more details for the allegations besides feeling isolated and not having a telephone to receive calls. On 05/26/2022, LPA Dolores interviewed 3 staff members. Based on staff interview, 3 out of 3 staff states the facility does have a telephone residents can use to make and receive calls. 3 out of 3 staff stated that R1 had never voiced that he/she did not feel safe or comfortable at the facility. S1 states that R1 would use the office phone to make sure R1 would be at his/her medical appointments as R1’s medical appointments were conducted via telephone. On 04/18/2024, LPA Rai and LPA Monter interview 3 residents regarding the allegation. Based resident interview, 3 residents (R6, R7, R10) stated the facility has telephones for the residents to use. Based on observation, the facility has operable telephones throughout the facility. It was alleged that the facility is not providing transportation to R1’s medical appointments. On 05/26/2022, R1 was interviewed. Based on interview, R1 stated he/she had not attended a single chiropractor appointment because the facility’s transportation will only pay for 15 miles. R1 stated his/her chiropractor appointment was 30 miles away. On 05/26/2022, LPA Dolores interviewed 3 staff members. Based on staff interview, the facility’s transportation radius is within 15 miles and if the resident wants to go further than the 15 miles, then the residents will be billed. S1 stated that R1’s medical appointments were conducted via telephone. PAGE 2 OF 4. S1 states that R1 did not have in-person appointments, that S1 knew of. S2 stated that R1 did not have any referrals to a chiropractor that they knew of. S1 and S2 states R1’s POA was really good at informing the facility staff of R1’s appointments. On 04/18/2024, LPA Rai and LPA Monter interviewed 9 residents regarding the allegation. Based on resident interview, the facility has a transportation service. 1 out of 9 residents states there is an issue with the transportation service as there were times were his/her transportation was cancelled the day of the appointment, therefore is now using a transportation service provided by his/her insurance. Based on review of the facility’s admission agreement, it’s indicated that the facility will make available scheduled transportation to medical and dental appointments, shopping areas and various social activities. It’s indicated that scheduled transportation within a twelve-mile radius of the community is provided and there may be an extra charge for services outside the service area. It was alleged that staff neglected the resident’s hygiene as R1 was not showered for a week. On 05/26/2022, R1 was interviewed. Based on interview, R1 stated the staff told him/her that he/she needed to shower as he/she started to smell bad. R1 stated that staff brought R1 bath towels and soap after requesting for the items. R1 stated that he/she did not shower for the first week of being admitted to the facility. On 05/26/2022, LPA Dolores interviewed 2 staff members regarding the allegation. Based on staff interview, S2 stated that during the first week of R1’s admission they were providing R1 reminders to shower. During the first week, they noticed R1 was not showering and during the initial assessment showering was something R1 would do. S2 stated they did have to remind R1 to take showers. S1 states to have never observed R1 had a foul odor but R1 was forgetting to do things and needed reminders. PAGE 3 OF 4. On 04/18/2024, LPA Rai and LPA Monter interviewed 4 residents regarding the allegation. Based on resident interview, it was stated that staff do help with showers. 4 out of 4 residents randomly interviewed stated to not need reminders to take showers. The review of R1’s records indicates that R1 is diagnosed with a neurocognitive impairment and is able to bathe self. R1’s initial service plan and preplacement appraisal did not include the need for showers. The Department has investigated the above allegations. Based on interview, record review and observation the above allegations are unsubstantiated. An unsubstantiated finding indicates that although the allegation is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Executive Director, Gregory Becker and a copy of the report was provided. PAGE 4 OF 4. It was alleged that the facility was holding resident (R1) against their will. Based on record review, R1 was admitted to the facility on 04/18/2022. On 05/26/2022, LPA Dolores interviewed 2 staff members regarding the allegation. Based on staff interview, R1 moved into the facility under respite care. R1’s POA wanted to see how R1 would do at the facility and try it out. S2 states that R1’s family was trying to find resources and was guided to an assisted living environment since R1 was unable to take care of themselves. S1 and S2 stated that R1 visited the facility 4 times before moving in and this was to ensure that R1 liked the facility. S1 stated that R1 voiced that he/she wanted to leave and S1 told R1 it was okay, and they can provide transportation. S1 stated that R1’s POA was saying that R1 could not leave because R1 has a neurocognitive impairment, and per R1’s POA’s instructions. S1 stated that R1 began saying that R1’s POA was holding him/her against his/her will, in which, S1 and S2 provided R1 with his/her POA documents. S1 and S2 denied holding R1 against his/her will. The review of R1’s records indicates that R1 is diagnosed with neurocognitive impairment and is unable to leave the facility unassisted. The review of records shows that R1’s POA for all powers including health care is the same person. It was alleged that the facility violated the resident’s rights by denying R1 on a group outing to the mall. On 05/26/2022, LPA Dolores interviewed 3 staff members regarding the allegation. Based on staff interview, 3 out of 3 staff stated R1 was allowed to go on group outings as their outings are supervised by staff. S3 oversees the outings and stated that R1 did not communicate with the staff that he/she wanted to join their outing to the mall. PAGE 2 OF 3. It was stated that R1 spoke with another resident at the facility and that resident did not inform the staff until they returned from the outing. S3 stated R1 was never denied outings. S3 advised R1 to communicate with the staff for next time. Based on record review, R1 signed in and out for outings on 04/21/2022 and 05/05/2022. The Department has investigated the above allegations. Based on interview and record review the above allegations are unfounded meaning the allegations are false, could not have happened, and/or is without a reasonable basis. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Executive Director, Gregory Becker and a copy of the report was provided. PAGE 3 OF 3.the state’s words, verbatim · CDSS document, Oct 3, 2024 · control 26-AS-20220517143434

Allegation investigated: Facility staff did not properly notify resident of rate increase.

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation report, and met with Executive Director (ED) Greg Becker. On 8/13/2024, the Department received a complaint that the facility increased the rate without notifying residents. On 8/23/2024, LPA conducted an initial investigation visit. LPA interviewed ED, 1 staff, and 3 residents. LPA requested document including a new 60 day notice of rate increase issued to R1, Assisted living care fee, R1's ledger of care level payment, and 1 copy of new 60 days notice of rate increase signed by R1. Continue on LIC9099-C. Page 1 of 2.. Unfounded Facility staff did not properly notify resident of rate increase: On 8/23/2024, LPA interviewed Executive Director (ED) Greg Becker. ED stated he/she starts to work for the facility at the end of January 2024. ED stated the previous management team issued a 60 day notice of rate increase to R1 in October 2023. ED stated the effective date of the rate increase is 1/1/2024. ED stated R1 claimed he/she did not receive the notice of rate increase and refused to pay. ED stated R1 still pays the old rate from 1/1/2024. ED stated the facility still provides the services without disruption. ED stated he/she cannot find the letter of rate increase sent to R1 in October 2023. ED stated the facility has made a decision to send R1 a new 60 day notice of rate increase and to take effective on 11/1/2024. ED stated the facility will waive the difference of the old rate and the new rate from January 2024 to October 2024. LPA interviewed Business Office Director (BOD). BOD stated he/she starts to work for the facility at the end of February 2024. BOD stated R1 talked to him/her about this issue around 2 months ago. BOD stated he/she checked R1's account and found R1 did not pay the increased rate, but just paid the old rate. BOD stated he/she was unable to find the letter of rate increase sent to R1 in October 2023. BOD stated he/she will waive R1's payment difference from January 2024 to October 2024. LPA interviewed resident R1. R1 stated he/she did not receive the notice of rate increase and he/she refused to pay the new rate. R1 stated he/she still receives the facility care and service without disruption. R1 stated he/she receives a 60 day notice of rate increase and the effective date of the new rate is 11/1/2024. R1 stated the facility will waive the difference between the old rate and the new rate from January 2024 to October 2024. R1 stated he/she agrees to pay the new rate starting 11/1/2024. Based on the review of R1' account ledger and documents, R1 did not pay the new rate since 1/1/2024. Based on the interviews, R1 receives the facility care and service as usual. LPA observed a copy of a new 60 day notice of rate increase dated 8/23/2024 with R1's signature. The Department has investigated the above allegation. Based on the investigation, records reviewed, and interviews, the Department found that the above allegations is UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. No citation noted today. Exit interview was conducted with ED. A copy of the report was provided to ED. Page 2 of 2.the state’s words, verbatim · CDSS document, Sep 17, 2024 · control 26-AS-20240813092234

Allegation investigated: Staff mishandling resident’s medication. Facility had an outbreak of norovirus.

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation findings and met with Executive Director (ED) Gregory Becker. On 05/08/2023, the Department received a complaint with the above allegations. On 05/18/2023, the Department conducted an initial investigation visit. LPA interviewed the previous Executive Director and one staff. LPA requested Resident .Physician report, Appraisal Needs and Services Plan, Admission Agreement and Medical records. Continue on LIC9099-C. Page 1 of 3. Unfounded Staff mishandling resident’s medication: On 5/8/2023, the Department received a complaint alleging staff mishandling resident's medications. It has been alleged resident R1's Medication #1 was not on the doctor prescribed medication list, and it has also alleged Medication #2 was not being administered. On 05/18/2023, LPA interviewed Director of Memory Care (DMC). DMC stated the facility staff administer medications to resident R1 based on the doctor's prescriptions orders. DMC stated R1's family member requested to stop Medication #1 for R1, but the facility staff explained to R1's family member that a medication cannot be stopped without R1's physician order. DMC was unable to provide the exact date that R1's family member requested to stop R1's Medication #1. Based on document review, Medication #1 was prescribed to R1 by R1's PCP to start on from 3/9/2023 to 3/30/2023, and the Medication #1 was stopped by the doctor on 3/31/2023 and the medication was not administered to R1 after 3/31/2023.. A review of R1's doctor prescriptions, there was no prescription given to R1 for Medication #2 and the Medication #2 was not found in R1's medication list. Based on the interview and review of R1's medical document, no evidence to indicate the facility staff mishandling R1's medications. Facility had an outbreak of norovirus: On 5/8/2023, the Department received a complaint alleging the facility having an outbreak of Norovirus. It has been alleged that the facility had an outbreak of Norovirus in April 2023. On 5/18/2023, LPA interviewed Previous Executive Director Lauren Powell (PED). PED stated in April 2023, the facility only has one Norovirus case of resident. PED stated the facility sent the incident report to Community Care Licensing (CCL) office. Continue on LIC9099-C. page 2 of 3. LPA interviewed Director of Memory Care (DMC). DMC stated there was no outbreak of Norovirus in the facility. An incident was sent to CCL office on 4/13/2023. DMC stated, the facility only had a case of Norovirus. DMC stated the resident was sent to hospital due to weak and was diagnosed Norovirus in the hospital. The Department reviewed facility incident reports sent to CCL office in April 2023, there is only one case of Norovirus case. Based on the interview and record reviewed, although the facility had a Norovirus case of resident, the facility only had one Novovirus case. The resident who had Norovirus was remained in the hospital to receive treatment, and the facility reported the Norovirus case to CCL office. There is no evidence to indicate the facility had a outbreak of Norovirus in April 2023.. The Department has investigated the above allegations. Based on the investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. No citation noted today. Exit interview was conducted with ED. The report was provided to ED for signature. A copy of the report was provided to ED. Continue on LIC9099-C. Page 3 of 3. Staff refusing to allow resident to have visitor(s): The allegation is that visitors are not allowed after 8:00PM and a family member was not allowed to visit right before 8:00PM. On 05/18/2023, LPA interviewed previous Executive Director (PED). PED stated the facility's policy for visitor is from 8:00AM to 8;00PM. PED stated visitors can stay in the resident rooms after 8:00PM if visitors enter the facility before 8:00PM. On 4/25/2024, the Department interviewed Resident Services Director (RSD). RSD stated if the visitor stay over 9:00PM, then facility staff will remind the visitors that it already 9:00PM, but the facility won't force visitors to leave the facility. The Department interviewed a staff who stated the visiting policy was from 8:00AM to 8:00PM and is changed to from 7:00AM to 9:00PM and stated if the time is too late sometimes the residents refuse the visitors but not the staff refuse the visitors. On 7/12/2024, LPA interviewed 4 staff. 4 out of 4 staff stated they did not force visitors to leave. 2 out of 4 staff stated staff remind visitors after 8:00PM, but staff did not force visitors to leave. LPA reviewed the facility visitor log, entries showed family members including R1's family member (FM) entering the facility right before 8:00PM and right after 8:00PM. On 7/12/2024, the Department interviewed FM. FM stated he/she was staying with R1 in R1's room but was unable to remember the exact date. FM stated he/she received a phone call from a staff that he/she needed to leave the facility because after 8:00PM. FM stated a staff also told him/her to leave because staff need to put residents in bed. FM stated staff did not physically force him/her to leave. FM provided 2 staff names (S1, S2) who notified FM to leave the facility. S1 and S2 already left the facility. LPA called S1 and left message. LPA called S2 and left message. LPA did not receive any response from S1 and S2. Based on the interviews and records reviewed, no evidence indicates the facility staff refusing to allow resident to have visitor(s). Continue on LIC9099-C. Page 2 of 3. Resident feels uncomfortable with a male caregiver: On 05/18/2023, LPA interview Director of Memory Care (DMC). DMC stated he/she grouped and scheduled groups of caregivers to serve groups of residents. DMC stated he/she tried the best to let female caregivers to take care of female residents and male caregivers to take care of male residents. DMC stated the staff are given a group of residents to take care during the shift. A staff is not assigned to a particular resident but a groups of residents. DMC stated the availability of staff is based on biological gender and preference of the families or residents. DMC stated the family must submit a formal request to the facility if they are not comfortable being cared for by the opposite biological gender. DMC stated there was no request that R1 required caregivers with the same biological gender with R1 until the end of March 2023. DMC stated within a week of the request, after 3/31/2023, R1 only receives the same biological gender caregiver for R1's showering service. R1's family member (FM) confirmed after 3/31/2023, R1 only receives the care from the same biological gender caregivers On 7/12/2024, the Department interviewed FM. FM stated it was under impression to have preference to have same biological gender caregiver for R1, but not sure if that specified in document or care plan. Based on document reviews of R1's Admission Agreement and pre appraisal information form, there is no statement of " receives the care from the same biological gender caregivers only". Based on the interviews, the facility changed to have only the same biological gender caregiver to serve R1 for showering service. Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. No citation noted today. This report was reviewed with ED, Gregory Becker and a copy of this report was provided. Page 3 of 3.the state’s words, verbatim · CDSS document, Sep 17, 2024 · control 26-AS-20230508123315

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced case management visit in regards an incident report, which stated a resident had eloped from the facility. LPA's met with Administrator Gregory Becker. LPA's explained the purpose of the visit. On August 26, 2024, the Department received an incident report, regarding resident R1. The incident report stated on August 20, 2024, at 12:10am, staff noted that resident R1 was not in his/her bedroom. Staff conducted immediately conducted a census of all memory care residents to account for the whereabouts of R1. During the census, local law enforcement arrived with resident R1, who was found outside the facility. On September 16, 2024, LPA interviewed 1 staff, and facility Memory Care Director. LPAs determined that the above incident requires further investigation. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Administrator Gregory Becker and a copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 16, 2024

Allegation investigated: Facility call system is in disrepair

Licensing Program Analyst (LPA) Maria (Mita) Partoza, conducted an unannounced visit to continue and deliver the finding of the complaint received by the department on 12/12/2023 regarding the allegation that the facility's call system is in disrepair. LPA met with Executive Director/Admnistrator Gregory Becker. On 12/19/2023, LPA Rai, conducted the initial investigations and interviewed 8 residents (R1 to R8), Staff 1 and 2 (S1 to S2). LPA Rai requested documents to include LIC 500 the resident roster, and the call bell system Invoices with a deadline of December 21, 2023 fron the Operatons Specialist. On 4/19/2024, LPA Partoza, continued the invesigation and reviewed the statements of the individuals who were interviewed. page 1 (see LIC 9099C for page 2) Unsubstantiated On 12/19/2023, LPA Rai conducted interviews with residents ( R1 to R8). Based on interview of R1 to R5 and R8, R1 to R5 and R8 does not use an emergency call pendant. R6 & R7 - uses an emergency call pendant, R1 to R8 have an emergency call button inside the bathroom that can be used in case of emergency. The emergency has a cord that residents need to pull for any life threatening situation. On 9/15/2024 at 12:10 p.m. LPA Partoza conducted additional interviews with staff (S3 to S7). Staff 4 (S4) demonstrated to LPA how the check in button works. At 12:10 p.m. LPA interviewed staff 4 (S4). S4 stated that the check in buttons is used to notify the facility that the resident is present in their apartment. A report listing the residents who checked in is printed each morning and if a resident's name does not appear on the list the front desk calls the resident and have a staff check on the resident. Residents should check in between the hours of 12:00 a.m. to 9:00 a.m. each day. At 12:15 p.m. LPA was accompanied by staff 3 (S3) to the memory care area and asked S3 to accompany LPA and demonstrate how the call button works. At 12:30 p.m. LPA interviewed S5, and S5 demonstrated how the check in button works, how they turn it off. In the memory care unit the staff are the ones who alerts the front desk and uses the check in buttons, the check in button has a red cord that they pull and is located in the bathroom. A red light flashes if the battery is low. At 12:45 p.m LPA interviewed staff 6 and 7(S6 and S7) and accompanied LPA to 2 resident's unit, of which one was recently vacated and 1 was occupied. S6 stated that the call buttons are used to check that the resident is in their room. S6 demonstrated that each resident has a pendant that is used to call the caregivers. S7 stated the check in is not for the caregivers but is used to account for the resident. S7 demonstrated how the check in button works and the pendant for each resident when pushed goes directly to the caregiver's pager. S6 demonstrated how a caregiver turns off the pendant. S5 demonstrated how the caregiver receives notification from the pendant. S6 and S7 stated that red light flashing from the check indicates low battery and maintenance is called to replace the battery. page 2 of 3 see LIC 9099C At 1:25 p.m. Executive Director/Administrator (ED/ADM) arrived at the facility. LPA interviewed ED/ADM and stated that the facility has the list (a copy provided) of the resident's who checked in from 12 midnight to 9:00 a.m. ED/ADM goes through the list and submit the report by 10:00 a.m. and saves the report in the office and is used as additional safety measure. ED/ADM stated if the battery is low, the system generates a report which unit needs the battery replaced. Based on interviews, document reviews, and observation, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were cited during today's visit per California Code of Regulations (CCR) Title 22. An exit interview was conducted with Executive Director/Administrator Gregory Becker and a copy of the report was provided. page 3 of 3 end of reportthe state’s words, verbatim · CDSS document, Sep 15, 2024 · control 26-AS-20231212142830

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Manuel Monter and Marcela Yanez conducted an unannounced case management visit in regards an incident report, which stated a resident had eloped from the facility. LPA's met with Administrator Gregory Becker. LPA's explained the purpose of the visit. On August 26, 2024, the Department received an incident report, regarding resident R1. The incident report stated on August 20, 2024, at 12:10am, staff noted that resident R1 was not in his/her bedroom. Staff conducted immediately conducted a census of all memory care residents to account for the whereabouts of R1. During the census, local law enforcement arrived with resident R1, who was found outside the facility. On August 28, 2024, LPA's interviewed staff S1-S9, and facility Memory Care Director. LPA's also interviewed resident R1. LPA's obtained copies of R1's progress notes, physician's report, needs and services plan. LPA's requested a copy of R1's Centrally stored medication record and Medication Administration Log. LPAs determined that the above incident requires further investigation. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Administrator Gregory Becker and a copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 28, 2024

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

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Case Management to conduct a Non-Compliance Plan Quarterly Visit and met with Resident Service Coordinator, Fely Arquero. Administrator was not present at the facility and busy at the time of the visit. The purpose of the visit is to ensure the facility is adhering to the Compliance Plan submitted to Community Care Licensing (CCL) after an informal meeting held on 04/26/2024. LPA Rai reviewed staff in-service training summaries conducted from 04/23/2024 - 07/30/2024 on topics included but not limited to: "Elopement", "Skin Breakdown Monitoring", "Reporting Change of Condition", "When and Why to Call 911", "Fall Reduction Program", "Preventing Heat Related Illness", and "Fire and Safety". Each in-service training included facility's policies and procedures on training topics. No deficiencies cited per California Code of Regulations, Title 22. This report was reviewed with Resident Service Coordinator, Fely Arquero and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 30, 2024

Allegation investigated: Staff physically abused resident

Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegation. LPA met with Administrator (ADM) Gregory Becker. On May 2, 2024, the Department received a complaint alleging staff physically abused resident. It has been alleged that a resident stated staff were abusive to him/her on April 15, 2024. On April 15, 2024, Local Law Enforcement (LLE) responded to a report that R1 was out of control and trying to hurt other residents and caregivers. Upon arrival, R1 kept saying staff hurt R1's hands and were abusive to him/her. LLE interviewed Staff S2, who stated he/she was trying to calm down R1. S2 stated R1 grabbed his/her fingers and twisted them. S2 stated R1 was also trying to bite him/her. S2 stated staff did not hurt R1 and were not physically abusive towards him/her. Page 1 Out of 3. Unfounded LLE interviewed staff S4, who stated R1 was screaming and yelling in the common area. S4 stated R1 grabbed the collar of his/her scrubs and was pushing staff. S4 denied hurting R1. LLE interviewed staff S5, who stated R1 was verbally aggressive staff and residents. S5 stated R1 tried to bite him/her and was pushing and hitting. S5 denied being physical towards R1. LLE attempted to interview R1, but R1 would not speak to LLE. LLE examined R1 for any visible injuries. LLE observed a band aid on R1's fingers. LLE did not see any bruising. On May 9, 2024, LPA Manuel Monter interviewed residents R1-R4. All residents interviewed stated the staff do not hurt residents and are very nice. All residents interviewed stated they do not remember the incident that occurred on April 15, 2024. All residents interviewed are located in the memory care unit. On May 9, 2024, and June 4, 2024, LPA Monter interviewed Staff S1-S5. Staff S2-S5 stated R1 was agitated and trying to hit staff and other residents. Staff S2-S5 denied the allegation that staff hurt R1’s hand and were abusive to him/her. Staff S1 stated he/she assessed R1 on the April 17 and did not see any signs of bruising or injuries noted. Based on a review of facility incident report, dated April 17, 2024, the incident report states on April 16, 2024, at 8:00pm, caregivers observed that R1 was agitated. R1 was walking down the hallway and trying to open the doors of the other residents and banging on the doors with his/her hands. Staff tried to de-escalate R1 to no avail. R1 tried to pick up chairs to throw them at the staff. R1 continued to be physically aggressive an attempted to bite the staff and spit at them. R1 was out of control and was showing signs of harm to other residents, staff and self. Medtech called 911 for further assistance. R1 was sent to Kaiser Santa Clara ER." Based on a review of R1’s Physicians Report, dated March 27, 2024, states R1 has a neurocognitive disorder. R1 is also confused/disoriented and may sun-down. Page 2 Out of 3. Based on a review of R1’s Needs and Services Plan, dated April 17, 2024, states R1 gets very agitated and would use walker to ram door/walls, try to hit and yell at staff. R1 is uncooperative and resistant to care assistance. 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. No deficiencies cited, an exit interview conducted with Administrator, Gregory Becker and a copy of the report was provided. END OF REPORT Page 3 Out of 3.the state’s words, verbatim · CDSS document, Jun 7, 2024 · control 26-AS-20240502140812

Allegation investigated: Facility's temperature is not within the required temperature Facility ventilation is not working causing odor

Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegation. LPA met with (ADM) Administrator Gregory Becker. Facility ventilation is not working causing odor On December 12, 2023, the Department received a complaint alleging facility ventilation is not working causing odor. On December 19, 2023, and April 18, 2024, The Department interviewed residents R1-R9. 7 Out of 9 residents interviewed stated they have not smelled any foul odors from the ventilation system. 2 Out of 9 residents interviewed stated the ventilation's system sometimes has a bad smell. Page 1 Out of 4. Unsubstantiated On December 19, 2023, LPA Rai interviewed facility Maintenance Director; MD. MD stated the facility’s ventilation has no issues. MD stated the filters are replaced every year and were recently changed in November 2023. On December 19, 2023, February 23, 2024, March 28, April 18, April 25 & May 9, 2024, the Department conducted unannounced visits to the facility. LPAs did not smell any foul odors coming from the ventilation system during these visits.. Based on a review of Facility work order, dated October 11, 2023, the facility had replaced its air filters on October 11, 2023. Based on investigation, records reviewed, and interviews conducted, 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 allegations did or did not occur. Facility's temperature is not within the required temperature On December 12, 2023, the Department received a complaint alleging Facility's temperature is not within the required temperature. On December 19, 2023, LPA Simi Rai interviewed residents R2-R9. 6 Out of 8 residents interviewed stated they had no issues with their room temperature. While interviewing residents, LPA noted R2-R9’s room temperature ranged from 74-78 degrees F. On April 18, 2024, LPA Monter interviewed resident R1. R1 stated the fuse box inside his/her room began sparking and the power stopped. R1 stated the heater was not functioning. R1 stated he/she does not remember the exact date when the issue with his/her fuse box occurred. R1 stated he/she did inform the maintenance director (MD). R1 stated the facility did not provide another room as a temporary option. R1 stated the home did not offer blankets or space heaters. R1 stated the issue was resolved on December 11, 2023. Page 2 Out of 4 On June 3, 2024, LPA Monter interviewed facility Maintenance Director (MD). MD stated he/she does not remember the full details regarding R1’s heating issues. MD stated R1’s bedroom breaker had loose wiring and was informed of the issue on a Sunday, when the fire department came to the facility. MD stated he check R1’s bedroom the same day, then contacted an electrician who came fixed the issue the following day. MD stated R1 decline a heater and told MD that he/she doesn’t need it. MD stated he/she did report it to the Executive Director, but reiterated that nothing was written down as it was a minor incident that was resolved relatively quickly. On June 7, 2024, LPA Monter interviewed former Executive Director (ED) Steven Harms. ED stated he did have discussion with MD regarding R1's room. ED stated he and the MD discussed providing ceramic heaters to R1, as they are safer than space heaters. ED stated he did not recall discussing with MD regarding R1 declining to use the portable heater. ED stated the conversations with MD were verbal and were not documented. Based on a review of Local Fire Department report, dated December 3, 2023, Local fire department responded to an incident which occurred in R1’s bedroom. The report states the fire department advised the responsible person to have a licensed electrician service the panel. The Department reviewed facility work order, dated December 5, 2023. The work order states R1’s bedroom’s power box was sparking on Sunday (December 3, 2023). The Department reviewed a facility work order for a sparking power box for R1’s bedroom. The work order states it was opened on December 5, 2023, and closed on December 6, 2023. The Department reviewed facility work order, dated December 11, 2023. The form states Maintenance Director (MD) reached out in regard to a bedroom, whose bedroom thermostat had no power. The form states the service was completed at 10:05am and there was no need to return. Page 3 Out of 4. Based on investigation, records reviewed, and interviews conducted, 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 allegations did or did not occur. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Administrator, Gregory Becker and a copy of this report was provided. END OF REPORT Page 4 Out of 4.the state’s words, verbatim · CDSS document, Jun 7, 2024 · control 26-AS-20231212112348

Type of visit: Office

A Noncompliance meeting was conducted on April 26, 2024 at CCLD San Jose office. Present at the meeting were San Bruno Adult and Senior Care Regional Manager Vivien Helbling, Licensing Program Manager Romeo Manzano, Licensing Program Analysts Simi Rai and Mita Partoza, Vice President of Operations Steven Harms, LVN Regional Resident Services Director Angelica Rothhaupt, and Executive Director/Administrator Gregory Becker. The purpose of the noncompliance meeting was to discuss the history of facility's serious violations cited under Title 22 California Code of Regulations to include Personal Rights, Incidental Medical and Dental Care, Observation of the Resident, Reappraisals and Reporting Requirements. Noncompliance Conference Summary LIC 9111 and compliance plans were established during the meeting. The facility will begin a 2 year monitoring plan by licensing which includes more frequent licensing inspections. The San Bruno Adult and Senior Care - San Jose Unit will refer the facility for legal consultation which may result in administrative actions such as possible Administrator De-Certification, License Revocation, or Employee Exclusion. The Licensee was informed during non-compliance meeting that additional civil penalties for serious bodily injury are pending review. RO will refer the facility to the Department’s technical support program (TSP) and provided a TSP brochure, Community Care Licensing Division (CCLD) website www.cdss.ca.gov. Report was reviewed with Licensee representatives. A copy of this report, LIC 9111 was provided to Licensee representatives during today's office visit.the state’s words, verbatim · CDSS document, Apr 26, 2024

Allegation investigated: Residents in care are not provided transportation services

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with the Administrator (ADM), Greg Becker and stated the purpose of today’s visit. On 11/21/2023, the Department received a complaint with the above allegations. On 11/29/2023, the Department conducted an initial investigation at the facility. It was alleged the facility staff suggested residents to cancel their appointments or figuring out their own transportation services. On 11/29/2023, the Department interviewed 3 staff, including the Administrator (ADM) Steven Harms. ADM stated the facility did not have a licensed driver to drive the facility bus. ADM stated the Activities Director took care of schedule/arranging transportation for the residents. Continuation on LIC 9099-C, Page 1 of 3. Substantiated Page 2 of 3. ADM stated the facility has provided a flyer to the residents to share resources, such as taxi and ride share companies for residents to schedule the transportation on their own. ADM stated the facility schedules the transportation appointments electronically to use the facility car/sedan which is available to use at this time. Based on the review of transportation services log, LPA Rai observed 1-2 residents signed up for transportation services every week from October 2023 to November 2023. 2 Out of 3 staff that are in charge of transportation services stated they’ve had to either reschedule medical appointments or request residents to cancel appointment that were already scheduled due to the availability of the driver. 2 staff stated they will drive the residents in the facility’s sedan/car vehicle however if the resident was on a wheelchair and cannot transfer to the sedan/car vehicle, then the resident is not able to go to their scheduled appointment. On 12/19/2023, the Department interviewed 8 residents. 6 Out of 8 residents did not need transportation services offered at the facility since they were independent, or family was able to provide transportation to and from medical appointments. 2 out of 8 residents stated they needed the facility to provide transportation services and the facility staff did not provide alternative options for when the transportation bus was not available. On 4/18/2024, the Department interviewed 11 residents. 7 out of 11 residents did not need transportation services offered at the facility since they were independent, or family was able to provide transportation to and from medical appointments. 2 residents declined to make comments about the transportation services provided by the facility. 2 residents stated they needed the facility to provide transportation services and they have not received the transportation services. R3 stated R3 was not able to go to scheduled medical appointment arranged with the Activities Director due to no driver hired by the facility. Resident (R5) stated his/her medical appointments have been schedule with the Activities Director to ensure transportation was available. R5 stated the Activities Director and Activities assistant have requested R5 to cancel the medical appointment the day of the scheduled visit due to driver was not available for transportation. R5 stated due his/her ambulatory status, R5 needs transportation to accommodate a wheelchair and the facility staff did not arrange for a substitution transportation accommodating for R5. Page 3 of 3. Based on review at random facility’s Admission Agreements for 7 residents, “Transportation” under Admission Agreements on page 5 of 71 stated the facility will make available scheduled transportation to medical and dental appointments, shopping areas and various social activities. Scheduled transportation within twelve-mile radius of the Community is provided. There may be an extra charge for services outside the service area and for escort services for those who need assistance. Based on review of Appendix E Resident’s Personal Rights of the Admission Agreement on page 38 of 71, 7 out of 7 resident’s agreement stated the facility may not deny or restrict medical or nonmedical care that is appropriate to a resident’s organs and bodily needs. Based on review of facility’s Plan of Operations updated on 7/3/2019, the facility will assist in arranging for a transportation provider for all other non-emergency transportation. Per document, it states “in all cases, the Community will ensure that the resident’s needs are met.” Based on interviews and observation/inspection of the facility, the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED. Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 9099-D. This report was reviewed with Administrator and a copy of the report was provided. Appeal Rights was provided. Page 2 of 3. Residents in care are not provided adequate meals. It was alleged the meat was tough, hard to chew, the meal portions were small, and vegetables were cooked until it had zero nutritional value. On 11/29/2023, the Department interviewed the Culinary Director who oversees the food service. CD stated all meals are reviewed by a nutritionist every 3 months and the receipts are pre-approved by a nutritionist. CD stated the residents are able to make requests on how they want the meal to be served when placing the order with the server and if the cook is able to fulfil the request, then they will arrange the substitution. CD stated they prepare the meat as set forth under FDA guidelines and residents can request for chopped meat when placing the order for the food. CD stated they serve the portions as set forth by the nutritionist, but the resident can always ask for second servings. On 12/19/2023, the Department interviewed 8 residents. 7 Out of 8 residents stated there was adequate meals at the facility. They stated they were served meals in good portion and the facility servers would bring them seconds if requested. Resident (R1) stated it is not easy to flag down a server for second servings since the servers are short staffed and by the time R1 requests for second serving, the kitchen is out of the special and facility staff will accommodate from standing menu. On 4/18/2024, the Department interviewed 11 residents. 1 resident cooked their own meals and did not use the food service at the facility. 2 residents declined to make comments about the meals served at the facility. 8 Out of 11 residents stated there was adequate meals at the facility. 8 residents stated they were getting enough portions as their entrée for lunch and dinner service. 8 residents stated they were able to consume the meat and often chopped the meat themselves and vegetables were cooked to their preference. Page 3 of 3. Staff do not ensure there is enough food supplies at the facility for residents in care. It was alleged that the facility did not have enough food supply to cook meals for the residents. On 11/29/2023, the Department interviewed the Culinary Director who oversees the food service. CD stated there are changes that are made on the meals served to the residents based on what is delivered to facility by the food vendor. CD stated once the staff accounts for the delivery, they are able to make changes to the menu and notify the residents of the change. CD stated the facility will always have 2 days of perishable food supplies and 7 days of nonperishable food supplies and 3 days of emergency food and water supply. On 11/29/2023, LPAs observed the food supply in the pantry, freezer, fridge, and kitchen. LPAs observed 2 days of perishable foods, 7 days of nonperishable foods and 3 days of emergency food and water supply. On 12/19/2023, the Department interviewed 8 residents. 7 out of 8 resident state the facility did have enough food supply to cook meals for the residents. Resident (R1) stated the facility did not have enough food supply since the resident was not able to order the special of the day, but the facility did provide a meal off of the standby menu while is always available for the resident. On 4/18/2024, the Department interviewed 11 residents. 1 resident cooked their own meal and did not have facility provide meals to him/her. 2 residents declined to make comments about the food supply at the facility. 8 out of the 11 residents stated the facility did have enough food supply at the facility. 8 residents stated they were served their entrée during breakfast, lunch and dinner and facility had provided snacks in the dinning room at all times. Based on the interviews conducted with clients and staff and based on observation and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Administrator, Gregory Becker and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 25, 2024 · control 26-AS-20231121112922

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(2) · Plan of correction due date: May 2, 2024

87465 Incidental Medical and Dental Care (a)(2) The licensee shall provide assistance ...In providing transportation the licensee shall do so directly or make arrangements for this service. This requirement is not met as evidenced by: Based on record review and interview, the facility did not provide transportation or make arrangements when facility did not have a driver for the facility van wherein residents were asked to re-schedule or cancel medical appointments which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 25, 2024

Plan of correction: Licensee/Administrator stated to submit a written plan of action understanding regulation and ensure transportation is provided for medical and dental care by POC due date. Licensee/Administrator agreed and understood. At this time, the facility has hired a driver to drive the facility van and was present at the facilty during today's visit.

Allegation investigated: Facility staff forcefully pushed resident to a wheelchair. Facility staff was rough when assiting resident with postural support.

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with the Administrator (ADM) Greg Becker and stated the purpose of today’s visit. On March 22, 2024, the Department received a complaint alleging facility staff was rough when assisting a resident with a postural support. It has also been alleged facility staff forcefully pushed a resident to a wheelchair. Continuation in LIC 9099-C, Page 1 of 3. Unsubstantiated Page 2 of 3. On March 21, 2024, Local Law Enforcement (LLE) interviewed resident, R1. R1 stated S1 entered his/her room and told R1 his/her dinner was here. S1 told R1 to that he/she needed to get up. R1 stated as he/she was walking towards the living room, R1 placed his/her hand on R1’s upper back and slightly pushed R1 forward. R1 stated the pushing didn’t increase his/her existing pain. R1 stated S1 tried to put on R1’s back brace, but S1 didn’t know how to properly secure it. R1 stated, he/she pressed her call button to summon help. R1 stated S1 had shaken the brace aggressively. R1 stated during this incident, staff S2 came for five minutes, but then left. R1 stated he/she did no tell S2 what had happened because R1 was scared. R1 stated S2 later returned and helped R1 back to the bed. R1 stated S1 has assisted her in the past. On March 21 and 27, 2024, LLE interviewed Staff S2 and Staff S3. S3 stated he/she received a call on his/her radio to help R1 with his/her back brace. S3 stated S1 looked upset. S3 stated he/she assisted R1 remove his/her back brace. R1 told S3 that S1 was aggressive with him/her but didn’t mention how. S3 stated he/she did not hear an argument or yelling prior to entering R1’s room. S3 stated he/she never saw S1 shake R1. LLE interviewed Staff S2. S2 stated he/she received a page that R1 pressed his/her alert pendant. S2 opened the door to R1’s apartment and saw R1 sitting in the couch chair in the living room. S2 saw S1 standing by the counter in the kitchen. S2 asked R1 why he/she pressed her pendant. R1 stated she needed help with his/her back brace. S2 stated he/she did not see S1 attempting to put the brace on R1. S2 stated he/she contacted another caregiver to help with the back brace. S2 stated R1 didn’t look scared or upset. On March 28, 2024, Licensing Program Analyst, Manuel Monter interviewed resident R1. R1 stated, S1 put the walker in front of him/her and then moved him/her by pushing him/her on the walker. R1 stated S1 pushed him/her until he/she got to the living room. R1 stated then when he/she arrived to his/her chair, S1 pushed him/her, to his/her chair. R1 stated he/she has a wheelchair, but he/she didn't use it that day. Page 3 of 3. On April 18, 2024, Licensing Program Analysts Manuel Monter and Simi Rai interviewed Resident Services Director, RSD. RSD stated the resident was assessed for bruises and/or marks. RSD stated R1 was observed to not have any bruises or marks. Based on a review of R1’s Progress notes dated March 23, 2024, a head-to-toe assessment was done on R1. No signs of bruising was observed. R1’s skin is intact and no reports from care staff of any skin issues. Based on a review of S1’s training records obtained during today’s visit, S1 received in-service training on 3/12/2024 for approximately 1 hour on “Donning/Doffing Brace” which was provided by Home Health Physical Therapist. Based on investigation, records reviewed, and interviews conducted, 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 allegations did or did not occur. No deficiencies were cited at this time as per California Code of Regulations Title 22.This report was reviewed with Administrator, Gregory Becker and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 25, 2024 · control 26-AS-20240322090615

Allegation investigated: Facility is not serving food at appropriate temperatures

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with the Administrator, Greg Becker and stated the purpose of today’s visit. On June 23, 2023, the Department received a complaint of an allegation that the facility was not serving the food at appropriate temperature. On June 30, 2023, LPA Chang conducted an initial investigation visit. LPA interviewed 2 staff and 2 residents. LPA toured the main kitchen, assist living unit dining room and memory care unit dining room. Continuation in LIC 9099-C, Page 1 of 2. Unsubstantiated Page 2 of 2. On June 30, 2023, around 9:10AM, LPA Chang toured and inspected the facility main kitchen and main dining room and interviewed a staff (S1). S1 stated the facility breakfasts were served from 7:30AM to 9:30AM, lunches were served from 11:30AM to 01:30PM, and dinners were served from 4:30PM to 6:30PM. S1 stated facility residents pick up their breakfast food at the food service counter. S1 stated there are staff serve the food at the food service counter during lunches and dinner. LPA toured the memory care unit dining room and Kitchenette. Staff S1 stated the food was cooked in the facility main kitchen and was transported to memory care unit Kitchenette via hotbox. S1 stated the food was kept warm in the hotbox. Juices and drinks were observed kept in the refrigerator. On June 30, 2023, and April 18, 2024, the Department interviewed 13 residents, R1-R13. 6 Out of 13 residents interviewed stated the food was hot and they had no complaints. 4 Out of 13 residents stated the food was not hot enough but staff did offer to heat it up if they requested. 1 Out of 13 residents stated does not eat food the facility provides and makes his/her own food. The remaining 2 Out of 13 residents stated they did not want to be interviewed. Based on investigation, records reviewed, and interviews conducted, 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 allegations did or did not occur. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Administrator, Gregory Becker and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 25, 2024 · control 26-AS-20230623152607

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Simi Rai arrived unannounced to conduct a Case Management visit and met with Administrator, Gregory Becker. The purpose of the visit is to follow-up on an incident report the Department received regarding medication error at the facility which occurred on 04/9/2024. On 4/10/2024, the Department received an incident report regarding a medication error for resident (R1) which resulted in R1 taking additional dosage of medication which exceeded physician's order. Based on interview with ADM and Resident Service Director (RSD), the facility manages R1's medication and R1's family brought and left medication in R1's room without the knowledge of facility staff. The facility's medication technician (Med-Tech) administered the medication as per doctor's orders. R1 administered two doses of medication on her own with the medication bottle available in the room. During visit, LPA Rai reviewed R1's Physician's Report dated 3/22/2024, which states R1 has Dementia and is not able to administer own prescription and PRN medications and is not able to store own medication. LPA Rai requests that Administrator, Gregory Becker submit a Plan of Action to address the ongoing staff training and mitigations that will be put in place to prevent future medication errors. No deficiencies were cited at this time as per California Code of Regulations Title 22. An Advisory Note was issued, please see LIC 9102. This report was reviewed with Administrator, Gregory Becker and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 25, 2024

Allegation investigated: Staff neglected a resident resulting in multiple fractures. Licensee does not adequately staff facility to meet residents’ high level of care and needs. Staff did not submit incident reports to Licensing.

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with the Executive Director, Greg Becker and stated the purpose of today’s visit. On 8/21/2023, the Department received a complaint with the above allegations. On 8/22/2023, the Department conducted an initial investigation at the facility. Based on the department’s investigation, resident (referred as R1) had motor impairment/paralysis and neurocognitive disorder and was considered fall risk. R1 required assistance with majority of his/her Activities of Daily Living (ADLs), which included standby assistance. Continuation on LIC 9099-C, Page 1 of 4. Substantiated Page 3 of 3. On 11/30/2023, the Department interviewed Staff (S1) who stated R1 preferred female caregivers and staff including Med-Tech would check on R1’s wet undergarments. On 12/19/2023, the Department interviewed staff (S2) who stated residents are checked every 2 hours and every 30-60 minutes if the residents prefer to stay in their room. S2 stated that during the day, there are 6-7 facility staff monitoring residents in the common area, which include 3-4 caregivers. Based on staff schedule from 8/13/2023 – 8/26/2023, there were 4 caregivers on schedule for AM shift (6am-2pm), 3 caregivers for PM shift (2pm-10pm) and 2 caregivers in NOC shift (10pm-6am). Based on the interviews conducted with clients and staff and based on observation and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED. No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Executive Director, Greg Becker and a copy of the report was provided. Page 2 of 3. Based on record review of R1’s Needs and Services Plan dates 2/22/2023, R1 needs total assistance for toileting, uses undergarments and R1 requires physical assistance with part of toileting tasks as well as daily skin checks due to skin condition to the groin/peri area. Based on Resident’s Care Summary, R1 was being assisted with frequent or unscheduled incontinence care, assistance with toileting for more than 3 times per day, which included bladder and bowel care. On 11/15/2023, the Department interviewed with Assisted and Independent Living Resident Services Director (AL/IL RSD), who stated most resident normally spend time in the living room, but if residents are in their bedrooms, then staff check on the residents hourly to assist with incontinence care. AL/IL RSD stated R1 required full assistance with incontinence care. Based on interviews conducted with staff (S1-S4), staff stated R1 would use the bathroom toilet and would rarely soil the undergarment. Staff would check on R1’s undergarments at minimum 5 times during AM shift (6am-2pm), at minimum 5 times during PM shift (2pm-10pm) and as needed during NOC shift (10pm-6am). Staff stated R1 would ask to be assisted to go to the bathroom and staff would provide stand-by assistance. S4 stated R1 had one episode of rash in the peri area, but it was resolved after using ointment in the affected area for a day. Staff stated R1 would verbalize if undergarments needed to be changed. S4 stated the facility does not document every time R1’s undergarments were changed, but it was a standard practice for staff to change the undergarments when soiled and during every shift change. S4 stated R1 would not remain in wet and soiled diapers for an extended period of time, since R1 would verbalize when to go to the bathroom, or the staff were regularly checking on R1’s undergarments. S4 stated the R1’s responsible party will provide incontinence products every 2 weeks. S4 stated they are changing the resident every shift and every day to ensure R1 has dry undergarments and would go through R1’s supply of incontinence products regularly. Page 2 of 4. Based on investigation, it was not clear on which caregiver was assigned to R1 on the days he/she sustained falls and injuries, which were 6/3/2023, 6/9/2023 and 8/13/2023. Staff recalled R1 wearing a foam splint on his/her pinky finger for a while. Staff were unaware that R1 fractured his/her ribs until the Department confirmed R1’s injuries based on medical records. Staff did not recall on how R1 sustained a dislocated left pinky finger and fractured ribs on 6/3/2023. Staff believed R1’s finger injury was from R1 scooting his/her chair forward and scrapping the fingers underneath a table. On 10/2/2023, the Department interviewed R1’s responsible party (RP). RP stated the first incident occurred on 6/3/2023. R1 sustained a hand injury when he/she was trying to sit down, and another resident (R2) pushed R1 out of the way. R1 was not seen by a medical doctor until 6/5/2023. An X-Ray was done on R1’s hand and ribcage since R1 complained of pain on the left ribcage. The results showed R1’s finger dislocated and R1 sustained injuries to the ribs. On 6/9/2023, the second incident occurred where R1 had another fall at the facility. R1 was pushed by another resident to the ground. The third incident occurred on 8/13/2023 when R1 was punched in the face by another resident in the living room. R1 began hyperventilating and was nauseous. On 12/14/2023, the Department interviewed the former Resident Services Director (RSD). RSD explained standby assistance is when staff will walk with the resident, supervising residents during showers or toileting, but the staff do not assist when residents are sitting down. RSD stated R1 fell one or twice when he/she attempted to use the restroom by himself/herself. R2 was sent out to the hospital for an evaluation but does not remember the specific date of when R1 fell. RSD stated that in April/May 2023, during dinner service, a resident pushed R1 out of his/her chair. RSD was not aware of R1 sustaining any injuries on his/her ribs or anywhere else but was aware that R1 sustained bruising to his/her left hand. On 11/30/2023, the Department interviewed staff (S1), S1 stated that he/she did not recall what happened when R1 sustained injuries to his/her left pinky finger, he/she did not recall when it happened. On 12/19/2023, the Department interviewed staff (S2), S2 stated that R1 is a fall risk who utilized a walker with standby assistance. S2 stated that R1 is not combative and does not have any self-injurious behaviors. Page 3 of 4. S2 did not know what happened or how R1 sustained the finger dislocation or the fractured ribs from 6/3/2023. S2 stated he/she not aware of R1 was brought to the hospital and had a brace on his/her finger and not aware of an altercation R1 had with another resident in 6/9/2023. On 12/14/2023, the Department interviewed Staff (S3) stated R1 lost her balance a lot and was a fall risk and needed a caregiver with her but did not have 1:1 supervision. On 11/15/2023, the Department interviewed with Assisted and Independent Living Resident Services Director (AL/IL RSD) who stated that staff is assigned to sit and supervise the residents but was unable to provide the names of staff who were assigned to provide care and supervise for 6/3/2023, 6/9/2023 and 8/13/2023. AL/IL RSD was also unaware of the 6/3/2023 and 6/9/2023 incidents. Based on available information gathered on the incident which occurred on 8/13/2023 in the living room where R1 and R2 had a physical altercation. 3 facility staff members heard both residents screaming and did not observe the residents' altercation. One staff member (S4) was in the kitchen/dining room when he/she heard R1 and R2 screaming and went to the living room and separated the residents after R2 hit R1 twice and R1 hit R2 back. R1 sustained a small cut and swollen upper lip and R2 had a small bruising marks on the hand. There was no documentation of a staff being present at the time of the altercation in the living room. A review of R1’s Physician’s Report dated 2/14/2023, R1 had a diagnosis of neurocognitive disorder and motor impairment/paralysis on the left side weakness and is confused/disoriented but does not have aggressive behavior. Based on record review of R1’s Needs and Services Plan dated 2/22/2023, R1 does not have current history of disruptive, aggressive, verbal or socially inappropriate behaviors. R1 needs protection and supervision because resident makes unsafe or inappropriate decisions. R1’s mobility and gait are limited and balanced is decreased with left sided paralysis and is able to ambulate with walker and one-person assist. Page 4 of 4. Based on the investigation, R1 was not reappraised after being involved in multiple physical altercations resulting in injury during the month of June 2023 and August 2023. Based on review of R1’s Progress Notes from 5/10/2023 – 8/22/2023, facility staff did not document any changes in physical functions and the appropriate assistance provided when observation reveals unmet needs. Based on the investigation and review of Incident Reports submitted by the facility, the Department did not receive an LIC 624 Unusual Incident / Injury Report from the facility for the incident which occurred on 6/3/2023. Based on review of email from Executive Director on 6/27/2023, R1 “bruised her finger. We do not have to report it to licensing” referring to the incident which occurred on 6/3/2023. The incident on 6/9/2023 and 8/13/2023 were reported to the Department wherein R1 sustained injury/fall after resident altercation. Due to the injuries sustained while the resident is under facility supervision, a written report shall be submitted to the Department within seven days of the occurrence of the event. As stated in California Code of Regulation 87211 Reporting Requirements, any incident which threatens the welfare, safety, or health of any resident need to be reported to the licensing agency. Based on interviews and record review of the facility, the preponderance of evidence standard has been met therefore the above allegations are found to be SUBSTANTIATED. Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 9099-D. An immediate civil penalty in the amount of $500 was assessed today. Additional civil penalties for the violation resulting in serious bodily injury is pending for further review. This report was reviewed by the Executive Director, Greg Becker and a copy of the report was provided. Appeal Rights was provided.the state’s words, verbatim · CDSS document, Feb 23, 2024 · control 26-AS-20230821105004

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Mar 1, 2024

87211 Reporting Requirements (a)(1)(D) Any incident which threatens the welfare, safety, or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by: Based on interviews and record reviewed, of incident reports submitted to the Department, a report was not filed with the licensing agency addressed R1's injury in June 2023, which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 23, 2024

Plan of correction: Licensee/Executive Director stated to submit a written plan of action understanding regulation by POC due date. Licensee/Executive Director agreed and understood.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Mar 1, 2024

87463 Reappraisals (a)...The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to... This requirement is not met as evidenced by: Based on record review, R1 did not have a reappraisal after multiple physical altercations in June 2023 and August 2023 which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 23, 2024

Plan of correction: Licensee/Executive Director stated to submit a plan of action understanding regulation by POC due date. Licensee/Executive Director agreed and understood.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Mar 2, 2024

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. This requirement is not met as evidenced by: Based on record review and interviews, R1's changes in physical, such as injuries sustained in resident to resident altercation, were not documented, which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 23, 2024

Plan of correction: Licensee/Executive Director stated to submit a written plan of action understanding regulation by POC due date. Licensee/Executive Director agreed and understood.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Feb 24, 2024

87465 Incidental Medical and Dental Care (a) (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: Based on interviews and record review, the facility staff did not follow up on R1's injuries and R1's responsible party transported R1 to the doctor's clinic 2 days after the incident, which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 23, 2024

Plan of correction: Licensee/Executive Director stated to submit a written plan of action understanding regulation by POC due date. Licensee/Executive Director agreed and understood.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Feb 24, 2024

87468.2 (a)(4)To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on interview and record review, Licensee did not ensure that resident R1 received care, supervision and services to meet R1's care needs, which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 23, 2024

Plan of correction: Licensee/Executive Director stated to submit a written plan of action understanding regulation and in-service training will ensure resident's rights are protected by POC due date. Licensee/Executive Director agreed and understood.

Allegation investigated: Facility does not maintain adequate staffing to meet resident's needs. Facility does not have planned activities for the residents.

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced complaint investigation visit to deliver the investigation finding, and met with Current Executive Director (CED) Mark Baddas. On 05/14/2021, the Department received a complaint with two allegations that facility does not maintain adequate staffing to meet resident's needs and facility does not have planned activities for the residents. On 05/19/2021, an initial investigation visit was conducted, ADM, 2 staff and 4 residents were interviewed. Resident Profile, Physician Report, and Service Evaluation Plans, Activities Calendar and Staff Schedule were obtained. Continue on LIC9099-C. Page 1 of 3. Unsubstantiated Facility does not maintain adequate staffing to meet resident's needs: On 05/19/2021, the Department interviewed Executive Director (ED) Dimple Kamdar. ED stated there were 3 residents in memory care unit, 1 resident in assisted living unit and 8 residents in independent living unit. ED stated the facility was actively hiring new staff because the facility just opened. ED denied the facility had low staff ratio because the facility only had 3 residents in memory care unit, and 1 resident in assisted living unit. ED stated the facility had new hired staff on training and another two new staff were just hired. ED stated there were 1 Med Tech/Caregiver, 1 nurse, and ED on duty for this shift not including house keepers and kitchen staff. On the same day, Med Tech (S1) was interviewed. S1 stated the facility had sufficient staff to take care of residents, most of time there were one care staff in memory care unit and one care staff in assisted living unit. On the same day, the Department interviewed 4 residents (R1 - R4). 4 Out of 4 residents stated that their needs were met, and they were taken well care of. On reviewing the documents, the facility had 5 care staff in April 2021 and 4 care staff in May 2021 to take care of residents. Based on the care staff schedule, the facility had at least one care staff at any time. Some of the time, the facility had one care staff at the facility, and he/she needed to take care of both sides of the memory care unit (MC) and assisted living unit (AL). Based on the interviews conducted and documents reviewed, Often times the facility had two care staff on duty, but some of the time the facility had one care staff on-duty and he/she needed to take care of both MC and AL units. ED stated the facility only had 4 residents in MC and AL units, he/she and other directors also helped to take care of residents. ED stated the facility had new staff on training and another two staff had just been hired. ED stated the facility encouraged the care staff to take overtime to take care of residents. ED stated the facility tried to maintain 2 care staff at AM and PM shifts by having staff working overtime. S1 stated the facility had sufficient staff to take care of residents. Both ED and S1 stated the facility had sufficient staff to take care of current residents. Continue on LIC9099-C. Page 2 of 3. Facility does not have planned activities for the residents: On 5/19/2021, the Department interviewed ED. ED stated the facility had a full time Activities Director Regina Brigham (S2), and a wide variety of activities were offered. On the same day, the Department interviewed S2. S2 stated the facility had Monthly Activity Calendar posted in advance. The facility had daily activity postings and offered text reminders to residents if they would like to participate. S2 stated he/she talked to residents at breakfast about activities planned for the day. S2 tried to get to know the residents on an individual basis to see what they would like to do. R1 likes puzzles and drawing, R2 likes exercise activities and just talking, R4 likes card games, and R3 likes quiet time. On the same day, the Department interviewed 4 residents. 4 out of 4 residents stated the facility offered activities. 2 out of 4 residents stated they were not interested in the activities. Reviewing the facility activity document, the facility offered a variety of activities and the facility had planned activities calendar. The Department observed residents participating in the activity in the facility during the visit. Based on the documents reviewed and interviews conducted, the facility offered a variety of activities, but not all the residents were interested in participating in the facility activities. The Department has investigated the above allegations. 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 allegations did or did not occur. No citations cited under California Code of Regulations Title 22. Exit interview conducted with Current Executive Director (CED). The report was provided to CED for signature. A copy of the report was provided to CED. Page 3 of 3.the state’s words, verbatim · CDSS document, Oct 18, 2023 · control 26-AS-20210514144310