Ivy Park at San Jose

Allegation investigated: Staff are not ensuring residents’ personal hygiene needs are met. Staff are not maintaining the facility in safe, sanitary condition

Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced complaint investigation visit to deliver the findings of the complaint received by the Department. LPA met with Business Office Director (BOD) Frank Lim and the manager in charge for the day. LPA stated the purpose of the visit. Executive Director/Administrtor Karina Nevarez was not available due to prior commitment. On 04/09/2026, the Department received a complint with the above allegations. On 04/10/2026, LPA Partoza conducted an initial investigation visit and subsequent visits were conducted on 04/29/2026, 05/05/2026, and 06/05/2026 to conduct interviews, inspect the Memory Care unit, gather information, and review resident records. See LIC 9099C for continuation page 1 of 4 Unsubstantiated Staff are not ensuring residents’ personal hygiene needs are met. On 04/10/2026 and 04/13/2026, LPA Partoza interviewed the Reporting Party (RP). RP stated residents in the Memory Care unit were observed wearing soiled clothing and exhibiting poor hygiene. RP stated resident laundry was not being completed and R1 was observed wearing soiled clothing and using bedding that appeared soiled. RP also reported concerns regarding R1’s oral hygiene and stated R1 developed multiple cavities since the previous dental visit. RP further expressed concern regarding R1’s history of urinary tract infections. On 04/10/2026, 05/05/2026, and 06/05/2026, LPA Partoza interviewed eight staff (S1, S2, S3, S4, S5, S6, S7, and S8). S1, S5, S6, S7, and S8 stated residents receive assistance with personal hygiene based on assessed needs, and clothing and bed linens are changed when soiled. S6, S7, and S8 stated R1 requires prompting with personal hygiene and that R1's clothing and bedding may become soiled due to food related behaviors. S2, S3, and S4 stated resident laundry is completed on a scheduled basis and additional laundry is completed as needed. On 04/10/2026, LPA Partoza attempted to interview R1; however, R1 responded in a language not familiar to LPA and did not provide information relevant to the allegation. LPA observed R1’s laundry basket was not overflowing and did not observe visible soiling on clothing stored in the closet. On 04/29/2026, LPA Partoza interviewed R2 and attempted to interview R3. R2 was unable to provide information regarding personal hygiene or laundry practices, and R3 was unable to provide information relevant to the allegation. On 05/05/2026, LPA Partoza interviewed R4. R4 acknowledged that the bathroom sink was clogged and stated “ok” when asked how R4 was doing and about staff. On 04/10/2026, LPA Partoza reviewed information received from RP, including email communications and photographs, R1’s Resident Assessment, and Individualized Service Plan (ISP). The records documented that R1 requires assistance with grooming, bathing, dressing, and toileting, and supervision and prompting due to memory impairment. The ISP also documented assistance with clothing and linen needs. page 2 of 4 On 04/10/2026, 04/29/2026, and 06/05/2026, LPA Partoza inspected resident rooms in the Memory Care unit, including rooms occupied by R1, R2, R3, and R4. LPA observed laundry baskets were not overflowing. Clothing worn by residents and clothing stored in resident closets had no visible staining or food residue. LPA did not observe visible soiling on the bed linens inspected. Based on interviews, inspections, and records reviewed, R1 requires assistance and prompting with personal hygiene. 5 Out of 8, staff stated residents receive assistance with personal hygiene and that clothing and bed linens are changed when soiled. During three inspections, LPA did not observe visible soiling on resident clothing or bed linens or overflowing laundry baskets. Staff are not maintaining the facility in safe, sanitary condition. On 04/10/2026 and 04/13/2026, LPA Partoza interviewed the Reporting Party (RP). RP stated the Memory Care common bathroom had an empty soap dispenser, sticky flooring, fecal residue on the toilet, and insufficient restroom supplies. RP also stated the kitchen sink soap dispenser was empty and housekeeping tasks were not being completed. RP provided photographs of the reported conditions. On 04/10/2026, 04/29/2026, and 06/05/2026, LPA Partoza inspected the Memory Care unit, including the common bathroom and resident rooms. LPA observed hand soap, toilet paper, paper towels, and toilet seat covers available in the common bathroom. LPA did not observe visible fecal residue on the toilet, sticky flooring, overflowing trash receptacles, or visible accumulation of debris during the inspections. On 04/29/2026, LPA also observed one resident bathroom sink draining slowly. Facility staff contacted S4, who responded to the concern, and LPA later observed the sink draining after the clog was cleared. On 04/29/2026 and 05/05/2026, LPA Partoza attempted to obtain information from Memory Care residents regarding the allegation; however, the residents interviewed were unable to provide information relevant to the condition of the common bathroom. page 3 of 4 On 04/10/2026, LPA Partoza reviewed information received from RP, including email communications and photographs depicting the reported conditions of the Memory Care common bathroom and resident areas. On 04/10/2026, 04/29/2026, and 06/05/2026, LPA Partoza inspected the Memory Care unit, including the common bathroom and resident rooms. LPA observed hand soap, toilet paper, paper towels, and toilet seat covers available in the common bathroom. LPA did not observe visible fecal residue on the toilet, sticky flooring, overflowing trash receptacles, or visible accumulation of debris during the inspections. Based on interviews, inspections, and records reviewed, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that staff did not ensure residents’ personal hygiene needs were met or that staff did not maintain the facility in a safe, sanitary condition. Therefore, the allegations are unsubstantiated. No deficiencies are being cited during today's visit based on the California Code of Regulation (CCR) Title 22. An exit interview was conducted with BOD/Manager in Charge of the day Frank LIm and a copy of the report was provided. Page 4 of 4 end of reportthe state’s words, verbatim · CDSS document, Aug 7, 2026 · control 26-AS-20260409145843

Allegation investigated: Staff did not provide adequate supervision resulting in resident wandering away from facility. Staff did not properly conduct pre-admissions assessment for resident. Staff did not follow resident's dietary plan.

Licensing Program Analyst (LPA) Maria (Mita) Partoza, conducted an unannounced visit to deliver the findings of the complaint investigation. LPA met with Executive Director/Administrator (ED/ADM) Karina Nevarez and stated the purpose of the visit. On 02/16/2026, the Department received a complaint with the above allegations. On 2/18/2026, 03/05/2026, 06/05/2026, 06/29/2026 and 07/08/2026 LPA Partoza interviewed staff, collected and reviewed documents and inspected the facility. See LIC 809C page 1 of 6 Unsubstantiated Facility staff did not provide adequate supervision resulting in resident wandering away from the facility. Based on information received from the Reporting Party (RP) and interviews conducted by LPA, RP stated R1 wandered from the facility building on two occasions after admission. RP further stated facility staff notified the family by telephone regarding the reported incidents and expressed concern that written incident reports were not provided. RP also stated R1’s behaviors changed after admission and expressed concern that R1 required Memory Care services. On 02/18/2026, 03/05/2026, 06/05/2026, and 06/29/2026, LPA interviewed seven staff (S1, S2, S3, S4, S5, S6, and S7). Five out of seven staff (S1, S2, S5, S6, and S7) stated R1 exhibited wandering or exit-seeking behaviors after admission. Six out of seven staff (S1, S2, S3, S5, S6, and S7) stated R1 wore an elopement bracelet. Five out of seven staff (S1, S2, S5, S6, and S7) stated staff located and redirected R1. Four out of seven staff (S2, S3, S5, and S6) stated R1’s condition changed after admission and additional supervision or Memory Care placement was discussed. S7 stated R1 was observed in the facility parking lot and did not recall R1 leaving the facility grounds. On 02/18/2026 and 06/29/2026, LPA observed designated exit doors equipped with an elopement alarm system. S9 demonstrated the operation of the alarm system. LPA observed the alarm activate when an elopement bracelet approached a designated exit. LPA reviewed progress notes and resident records. Progress notes documented R1 exhibited wandering and exit-seeking behaviors after admission. Progress notes documented implementation of an elopement bracelet, redirection, increased supervision, hourly monitoring, reassessments of care needs, and communication with the responsible party regarding changes in R1’s condition. Progress notes documented R1 was redirected while on facility property. Progress notes further documented the responsible party reported R1 had not wandered or left home alone prior to admission. page 2 of 6 Facility staff did not properly conduct a pre-admission assessment for resident. Based on information received from the Reporting Party (RP) and interviews conducted by LPA, RP stated facility staff did not disclose to the family during the admission process that the facility’s Memory Care unit was full. RP further stated S2 and S6 did not meet with the family to discuss the Resident Individualized Service Plan and S6 was not present during the Admission Agreement signing meeting. RP also stated the LIC 603 Pre-Admission Appraisal was provided by facility staff and signed by a family member on 10/23/2025 after the Admission Agreement was signed on 10/21/2025. RP stated the Resident Individualized Service Plan and Cost of Care Communication were marked “Draft” and expressed concern that the facility did not reassess R1 after changes in R1’s behavior. On 02/18/2026, 03/05/2026, 06/05/2026, 06/29/2026, and 07/08/2026, LPA interviewed seven staff (S1, S2, S3, S4, S5, S6, and S8). Two out of seven staff (S1 and S2) stated the pre-admission assessment was completed using the information available before admission. Four out of seven staff (S1, S2, S4, and S8) stated the family requested or toured Assisted Living and did not request Memory Care placement before admission. Two out of seven staff (S1 and S2) stated the family did not disclose wandering behaviors or concerns that R1 required a higher level of care before admission. Three out of seven staff (S2, S3, and S5) stated the facility’s Memory Care unit had no vacancy when Memory Care placement was discussed. Three out of seven staff (S2, S3, and S5) stated the facility discussed increased supervision, companion care, or alternative Memory Care placement with the responsible party after R1’s condition changed. S8 stated the Admission Agreement and Cost of Care Communication were completed during the admission process. During a follow-up interview conducted on 07/08/2026, S2 stated the facility’s Memory Care unit had no vacancy when R1 was admitted and the responsible party agreed to Assisted Living placement until a vacancy became available. S2 stated the facility later offered transfer to two sister communities with Memory Care, offered to waive move-in costs and pay moving expenses, and the responsible party declined the transfer because the Memory Care rate was higher. S2 further stated the facility requested one-to-one companion care due to R1’s increased wandering and inappropriate behaviors. page 3 of 6 LPA reviewed the Physician’s Report (LIC 602), Medical Assessment (LIC 602A), Pre-Admission Assessment, Resident Assessment, LIC 603 Pre-Admission Appraisal, Admission Agreement, Resident Individualized Service Plan, Cost of Care Communication, progress notes, and correspondence exchanged between the responsible party and the facility. The Physician’s Report (LIC 602), Medical Assessment (LIC 602A), Pre-Admission Assessment, Resident Assessment, and LIC 603 Pre-Admission Appraisal documented the information available before admission and did not document wandering behaviors, exit-seeking behaviors, or a need for Memory Care placement before admission. Progress notes documented changes in R1’s condition after admission, implementation of an elopement bracelet, reassessments of care needs, increased supervision, communication with the responsible party, discussion of companion care, and discussion of alternative Memory Care placement. Progress notes dated 12/11/2025 documented the responsible party declined transfer to another Memory Care community because the monthly rate exceeded the family’s price range and requested referrals for companion care agencies. Progress notes dated 12/20/2025 documented the responsible party agreed with the recommendation for 24-hour companion care. Facility staff did not follow the resident’s physician-ordered dietary plan. Based on information received from the Reporting Party (RP) and interviews conducted by LPA, RP stated the facility did not follow the physician-ordered diabetic diet identified on the Physician’s Report (LIC 602). RP further stated the family observed R1 consuming desserts and other foods the family believed were not consistent with a diabetic diet. RP also stated the physician-ordered diabetic diet was not reflected on the Resident Individualized Service Plan. page 4 of 6 On 02/18/2026, 03/05/2026, 06/05/2026, and 06/29/2026, LPA interviewed five staff (S1, S2, S3, S5, and S6). One out of five staff (S5) stated physician-ordered dietary information was communicated to dietary staff and meals were prepared according to physician orders. One out of five staff (S5) stated alternate meal choices were available when residents declined the offered meal. Two out of five staff (S5 and S6) provided information regarding R1’s meal service and dietary supervision. S5 stated residents were encouraged, but not forced, to follow physician-ordered diets. S6 stated R1 was encouraged to eat meals in the dining room where staff could provide supervision. S6 further stated staff removed individual coffee creamers from R1’s access after observing that R1 collected and consumed the creamers. On 03/05/2026 and 06/29/2026, LPA observed the facility kitchen, pantry, refrigerator, freezer, posted menu, and meal service. LPA observed dietary information identifying residents requiring physician-ordered diets was available to dietary staff for meal preparation. LPA observed residents were offered meal choices consisting of protein, carbohydrate, vegetable, and dessert options. LPA observed food inventory maintained for meal preparation. LPA reviewed the Physician’s Report (LIC 602), Medical Assessment (LIC 602A), Dietary Information Sheet, Resident Individualized Service Plan, medication records, progress notes, facility menu, and the facility’s Diabetes Culinary Program. The Physician’s Report (LIC 602) documented a physician-ordered diabetic diet. The Dietary Information Sheet documented physician-ordered dietary information was communicated to dietary staff for meal preparation. The Diabetes Culinary Program documented procedures for preparing meals for residents requiring diabetic diets, including diabetic-friendly meal options, substitutions, sugar-free desserts, and communication of physician-ordered dietary information to dietary staff. The Diabetes Culinary Program also documented residents may choose their own food selections. page 5 of 6 Based on interviews conducted, observations made, and records reviewed, progress notes documented changes in R1’s condition after admission, reassessments of care needs, increased supervision, implementation of additional interventions, and communication with the responsible party. Admission records documented a pre-admission assessment was completed for R1 using the information available before admission. The Dietary Information Sheet documented physician-ordered dietary information was communicated to dietary staff for meal preparation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations occurred; therefore, the allegations are unsubstantiated. No deficiencies were cited based on the California Code of Regulations, Title 22. An exit interview was conducted with Executive Director/Administrator (ED/ADM) and a copy of the report was provided. page 6 of 6 end of reportthe state’s words, verbatim · CDSS document, Jul 24, 2026 · control 26-AS-20260216134721

Type of visit: Case Management - Incident

On 06/17/2026, at 4:10 p.m. Licensing Program Analyst (LPA) Maria (Mita) Partoza, conducted an unannounced case management visit for incident that occurred at the facility on 06/12/2026. LPA met with Executive Director/Administrator (ED/ADM) Karina Nevarez, stated the purpose of the visit. The facility self reported to the department the event that occurred on 06/11/2026 regarding the incident between 2 residents in the memory care section of the facility. Based on the report submitted, on 06/11/2026, at approximately 1:15 p.m. staff/team members heard a commotion in the activity room and observed resident 1 (R1) and resident 2 (R2) were beside one another and were angry at each other. R1 sustained a superficial scratch on his/her face below the chin and staff intervened and separated the residents. During today's visit 06/17/2026, LPA conducted an interview with ED/ADM (S1) and Health Services Director (S2), ,who stated that the facility have notified R1s and R2S family and both families are aware of the resident's behaviors. S1 stated that R1s family member said that R1 does not like when someone get close to R1 and will ward off the person near him/her. S1 stated that no staff witnessed the actual altercation, but staff heard the commotion and turned around then intervened. LPA collected information pertaining to the incident. At this time, this case in under review and department will conduct a follow up visit , if warranted. No deficiencies were cited during today's visit based on the California Code of Regulations (CCR) Title 22. A copy of the report was provided to Executive Director/Administrator, Karina Nevarez. end of reportthe state’s words, verbatim · CDSS document, Jun 17, 2026

Type of visit: Case Management - Other

On 05/05/2026, LPA Maria (Mita) Partoza, conducted an unannounced visit to amend the finding of the complaint investigation that was filed with the department on 04/02/2026. LPA met with Executive Director/Administrator (ED/ADM) Karina Nevarez. This case management-other is being created to capture the time and date of visit that LPA Partoza amended and delivered the updated report for complaint number 26-AS-20260402150201. The findings were delivered on 04/09/2026 and based on the additional information received on 04/29/2026 the information was included in the report to address the allegation that staff did not ensure that resident’s’ bed is kept in good repair. No deficiencies were cited during today's visit and a copy of the report was provided to Executive Director/Administrator Karina Nevarez.the state’s words, verbatim · CDSS document, May 5, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced required 1 year inspection and met with Associate Executive Director/Administrator (AED) Val Baldugo and stated the purpose of the visit. Executive Director/Administrator (ED/ADM) arrived at a later time. The facility serves adults ages 60 and over, 140 non-ambulatory, 21 may be bedridden and hospice waiver for 15. LPA toured the interior of the facility, including entryway, lobby, resident room hallway, common area, dining area, kitchen, fire escape staircase, laundry room, emergency food supply area, medication room, activity area, 6 Assisted Living (AL) resident rooms, and 4 (2 shared & 2 private) Memory Care (MC) resident room and bathrooms. LPA observed that designated emergency exits are clear from obstruction and tripping hazard, however, LPA observed yellow caution tape on the entry ways due to ongoing exterior facility maintenance. Facility is a three story building, reception lobby where most residents sits, socialize, meet friends, and wait for their transportation. The exit doors are equipped with wander guard that alerts staff for resident who have exit seeking behaviors. Facility has activities scheduled posted for the whole month of April and posted conspicuously in the facility hallways, dining area, elevator, hallways, residents in the AL area received monthly activity calendar of events. LPA observed residents participating during one of the activity time in the MC and the AL area. page 1 of 2 MC area of the facility is equipped with delayed egress and working audible alarms. LPA observed rodent traps under the counter cabinets of the MC Unit. LPA did not observe any food stored that may be attracting the rodents. AED stated that the counter top with the food warmer is not in use. The facility kitchen is equipped with walk-in commercial grade refrigerator and freezer. Doors going to the kitchen have locks when not in used and are not accessible to residents. LPA observed emergency drinking water supply, 7 days for non-perishable food and emergency food supply (easy to prepare meal). The facility has snack bars in the activity areas. The kitchen is kept sanitary and organized. LPA inspected the freezer area, and observed that the facility has sufficient perishable food supply for 2 days or more. The walk-in refrigerator and freezer is cleaned 3 times or more a week. The dishwashing area and hot water temperature delivers over 125 degree F and warning sign is posted that the tap delivers hot water over 125 degree F. Kitchen staff were observed sweeping, wiping surfaces and organizing the kitchen after morning meals were served. LPA observed the dining area floors are kept sanitary. There were residents still present at the dining area at the time of inspection. The refrigerator temperature is at 31 degree F and the freezer temperature is at 0 degree F. LPA inspected assisted living (AL) residents room and memory care (MC) resident room. LPA observed that resident rooms have sufficient storage space for their personal belongings. Based on 5 out of 5 staff interviews, AL and MC are cleaned once a week and laundry are done once a week. Unless otherwise necessary, such as emergencies and behavioral challenge such as but not limited to smearing food and throwing food. The caregivers, and medication technicians will step in to keep the residents room in a safe and sanitary condition to prevent any infestation of ants and other insects, especially when housekeeping is not available. Based on review of the admission agreement extra cleaning for the week will incur a fee. The resident rooms were observed to be sanitary and organized. The AL and MC hot water temperature were measured with a digital thermometer, the temperature ranges between 115 degree F to 118.9 degree F. page 2 of 3 LPA conducted 5 staff interview and interviewed 5 residents in the AL area and 1 in the MC area. LPA reviewed 10 staff record for current training, background clearance, personnel file and current certifications. LPA reviewed 10 resident record such as individual care plans, physician's report (LIC 602), personal rights, admission agreement, consent forms to name a few. Medication record will need to be reviewed at a future date due to time constraint. LPA conducted a facility file review and verified that the facility conducts the fire and disaster drill training each month and given by Fire Safety Service, Inc. The last drill training was given on 04/13/2026. The facility maintains Ecolab to monitor and exterminate possible pest in the MC area. Based on record review Ecolab comes to the facility each month and or as needed to monitor the traps set at the MC kitchen area. The facility has fire extinguishers that are strategically placed in each floor and were last inspected on 05/15/2025 and 05/19/2025. The facility is equipped with fire alarm and carbon monoxide alarm system. The facility has a fire alarm panel that alerts the fire department in case of a fire. The facility is equipped with manual wet standpipe to be used in case of fire and water sprinklers. The facility ha emergency evacuation chairs for each fire escape staircase. Due to time constraint the required 1 year annual inspection will be continued at a later date. No deficiency was cited during today's annual required visit. An exit interview was conducted with Executive Director/Administrator (ED/ADM) Karina Nevarez and Associate Executive Director (AED) Valerie Baldugo and a copy of the report was provided. page 3 of 3the state’s words, verbatim · CDSS document, Apr 29, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst conducted an unannounced case management visit regarding the incident report received on 04/10/2026. LPA met with Associate Executive Director (AED) Valerie Baldugo and stated the purpose of the visit. The facility is licensed to serve adults age 60 and over, 140 non-ambulatory, of which 21 may be bedridden and hospice waiver for 15. LPA conducted an interview with the AED (S1) and Memory Care Director (MCD) (S2), and inquired about the incident that happened between two residents. The incident was reported by the facility to CCLD and states that resident 1 (R1) (diagnosis: dementia/Major NCD) stated that resident 2 (R2) and roommate (diagnosis: dementia/Major NCD) hit R1 with a book during the overnight hours of 04/08/2026 into the early morning of 04/09/2026. Both residents reside in memory care. Staff 3 (S3) was present, and observed R2 in bed throughout the night asleep. Memory Care Director (MCD/S2), assessed R1 and did not observe any injuries on R1 head. MCD/S2 observed and noted that there were no books in the apartment. R1s family was offered an upcoming private suite but declined due to financial concern. LPA requested documents for 2 out of 2 residents such as but not limited to physician's report (LIC 602), and individual care plan. LPA conducted a site inspection and during the site inspection, LPA was met with R1's spouse and child who resides in a different country and was on a video call with his/her parents. LPA was able to interview R1 and provided additional information. LPA met R2 but was not able to answer questions. S1 stated that a plan to move R1 or R2 to a different room is being considered. At this time, this case in under review and department will conduct a follow up visit, if warranted. No deficiencies cited during today's case management visit based on CCR Title 22. A copy of the report was provided to AED Valerie Baldugo.the state’s words, verbatim · CDSS document, Apr 10, 2026

Allegation investigated: Staff dId not ensure that resident’s’ bed is kept in good repair.

*** This report is being AMENDED due to additional information received. SEE PAGE 2**** LPA Maria (Mita) Partoza conducted an unannounced visit to deliver findings regarding the allegation that staff did not ensure residents’ beds were kept in good repair. LPA met with Associate Executive Director (AED) Valerie Baldugo and stated the purpose of the visit. The Department received the complaint on 04/02/2026 and conducted the initial 10 day investigation on 04/03/2026. LPA inspected resident rooms, interviewed staff and residents and requested documennts. page 1 of 2 see LIC 9099C Unfounded On 04/03/2026 - Three resident(R1 to R3) and one staff (S1) were interviewed. S1 stated that rooms are initially unfurnished and residents generally supply their own furniture, including beds. The facility provides basic furniture only for residents without their own, and facility provided beds are repaired or replaced by maintenance when needed. S1 also stated that some Assisted Living residents use hospital beds supplied through their insurance, and those beds are serviced by the corresponding DME vendor. The facility assists residents in contacting vendors as needed. 1 Out of 3 residents declined to be interviewed, 1 Out of 3 does not have information on who supplied their bed, and 1 Out of 3 is waiting to get their hospital bed repaired from the hospital bed provider. 1 Out of 3 residents stated they are aware that CCLD does not have jurisdiction over beds not supplied by the facility. Inspection showed that all three residents had hospital beds with vendor information on the bedframe. Facility documents indicated that hospital beds are not provided by the facility and are not included in the admission agreement. ****Additional information On 04/29/2026, LPA randomly inspected 4 memory care room (2 shared and 2 private (R4 to R7) that uses medical beds and 6 resident (R8 to R13) in assisted living. 2 out of the 6 resident in the AL uses hospital bed, which are in good working condition. LPA conducted interviews with 5 staff (S2 to S6), S2 & S6 stated that they have not seen a broken bed in the MC & AL section. S3 and S5 stated that R1 did complain about the noise that R1s medical bed was making but did not see any visible break on the frame, or bolts coming off and no oil leaking from the bed. S3 & S5 stated they reported R1s complaint about his/her bed making a noise to S4 and S4 came and checked on the bed. S4 stated if it is a loose bolt that needs tightening, maintenance will tighten the bolt, however, because of liability issue maintenance cannot repair a broken medical bed which was issued to the resident by their medical provider. S4 stated to facilitate repair of a broken medical bed or beds, the residents or caregivers calls the front desk to request for service. Maintenance will check on the problem and either repair or refer the issue to the management team. If it is a medical bed management assists resident in contacting their medical supplier to get their medical bed either replaced or repaired. This agency has investigated the complaint alleging that staff did not ensure that resident’s’ bed is kept in good repair. 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 deficiencies were cited based on the California Code of Regulations (CCR) Title 22. An exit interview was conducted and a copy of the report was provided to AED Valerie Baldugo. End of reportthe state’s words, verbatim · CDSS document, Apr 9, 2026 · control 26-AS-20260402150201

Allegation investigated: Facility did not provide written report to responsible party of resident's medical condition.

Licensing Program Analyst (LPA) Maria (Mita) Partoza, conducted an unannounced complaint investigation visit to deliver the findings of the above allegation. LPA met with Associate Executive Director (AED) Valerie Baldugo and stated the purpose of the visit. Executive Director (ED) Karina Nevarez was not present due to prior commitment. On 09/02/2025, the Department received a complaint with the above allegation. On 09/03/2025, the Department conducted an initial investigation and requested documents. On 01/09/2026, 01/27/2026 and 02/05/2026, the Department continued with the investigation. On 09/02/2025, LPA Steve Chang conducted an initial interview with witness 1 (W1). W1 stated that resident 1 (R1) was observed with a bruise and a skin tear on 07/28/2025 by witness 2 (W2). W1 stated that he/she did not observe the bruise himself/herself. W1 stated according to W2 the bruises were healing when W2 observed the bruise on 07/28/2025. ~~~~~ page 1 of 3 see LIC 9099 C Unsubstantiated On 01/09/2026, LPA Partoza interviewed 2 staff. Staff 2 (S2) stated that R1 was observed with tiny bruises 6 months ago and was reported to R1s PCP. Staff 3 (S3) stated that R1 bruises easily and does not know how R1 gets the bruises. On 02/05/2026, LPA Partoza interviewed W2. W2 stated that the facility did not notify R1s responsible party (RP) of the injury that R1 sustained a wound when R1 hit his/her foot on the wheelchair, however, W2 stated that “staff at the facility are typically good at reporting this type of incident to R1s RP.” W2 stated that the facility notified RP via phone on 08/28/2025, that R1s foot had a fluid filled blister on the left heel. Based on R1s general chart notes from 07/12/2025 to 08/27/2025 there was no incident reported describing a wheelchair related injury, however, documentation from 08/25/2025 to 08/27/2025 noted lethargy and poor appetite. On 08/28/2025, general chart notes documented discovery of a blister, photo taken, and notification to the responsible party (RP), primary care physician (PCP) and former memory care director (MCD). Additional information that RP and PCP were notified later the same day. The facility reported the incident to Community Care Licensing Division (CCLD) on 09/02/2025. Based on the R1s medical assessment dated 08/29/2025 R1s injury described a “serious foot injury requiring medical intervention.” Based on the policy review, the facility has a reporting policy consistent with California Code of Regulations (CCR) Title 22 section §87211, which requires facilities to notify the Department, the resident’s responsible party, and other appropriate agencies of incidents that pose a risk to resident health, safety, or personal rights. During the investigation, documentation disclosed that the facility notified the responsible party (RP), primary care provider (PCP), and memory care director (MCD) on 08/28/2025 when R1’s left heel blister was discovered and later submitted the incident report to the Department on 09/02/2025, consistent with the reporting timelines and procedures outlined in CCR §87211. page 2 of 3 see LIC 9099C Based on interviews and record review, the facility demonstrated compliance with its reporting obligations as required under §87211, R1s general chart notes did not contain written report regarding earlier wheelchair related injury. Based on interviews and record reviews that pertains to the left-heel blister observed on 08/28/2025, although the allegation that the facility did not provide written reports to responsible party of resident’s medical condition 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 based on CCR Title 22. An exit interview was conducted with AED Valerie Baldugo and copy of the report was provided. page 3 of 3 end of reportthe state’s words, verbatim · CDSS document, Mar 11, 2026 · control 26-AS-20250902144233

Allegation investigated: Resident sustained pressure injury due to neglect and lack of supervision Facility did not seek timely medical attention for resident's pressure injury

Licensing Program Analyst (LPA), Maria (Mita) Partoza, conducted an unannounced visit to deliver the findings of the complaint investigation. LPA met with Executive Director (ED) Karina Nevarez and stated the purpose of the visit. On 09/02/2025, the Department received a complaint with the above allegations. On 09/03/2025, the Department conducted an initial 10-day investigation visit. On 12/03/2025, the Department received the medical records of Resident 1 (R1). On 01/09/2026, 01/27/2026 and 02/05/2026, the department continued the investigation. LPA Partoza conducted interviews and reviewed received documents such medical assessment, appraisal needs and services plan and progress notes. see LIC 9099C page 1 of 4 Unsubstantiated On 09/02/25, LPA Chang interviewed Witness 1 (W1). W1 reported that on 08/29/25, Resident 1 (R1) and R1’s responsible party (RP) met with R1’s wound care physician for treatment of a Stage 1 pressure injury. W1 stated that based on his/her observations, W1 believes R1 experienced neglect or lack of supervision by the facility. W1 stated that the facility applied a Band-Aid to R1’s wound and did not provide timely or appropriate wound care. W1 further indicated that facility staff were responsible for R1 sustaining the pressure injury on his/her heel. W1 further states that RP told W1 that around 07/28/25, RP saw bruises on R1s arms and a skin tear, there was no report or documentation of the injury. RP continued to state to W1 that RP inquired about the injury with the former Memory Care Director (MCD) who stated that he/she will investigate the bruises but did not give an update to RP. On 01/09/26, LPA Partoza continued with the investigation and interviewed 3 staff (S1 to S3). S1 stated that he/she is not aware of R1s pressure injury on the foot, however, remembers R1 having a pressure injury prior to moving to MC, and it was on the back, it is no longer there. S2 stated R1 gets upset with care and is aggressive. S2 stated R1 can bruise easily because of his/her heart medication. S2 stated R1 came from a different facility, and he/she had a pressure injury on the back at that time. S2 stated that he/she remembers that R1 developed a pressure injury on his/her heel, but not sure how. S2 stated that caregivers elevate R1s legs every two hours. S2 stated when the medication technicians (MT) on duty was notified by the care staff of R1s wound, MT called the doctor and notified RP right away S2 stated R1 has a lot of skin problems on his/her legs, and memory care staff take care of R1. S2 stated "currently, R1s pressure injury is healing well." S3 stated that "R1 is aggressive especially during his/her ADLs, R1 likes to punch, kick and flay his/her arms to staff. It will take three care staff to change R1." S3 stated he/she "I put cream on R1s rashes. R1 skin is very sensitive. When he/she move R1 foot to elevate, R1 screams because it's painful. R1 will say ouch, ouch whenever they move or reposition his/her foot." On 01/27/2026, LPA interviewed 1 staff (S4). S4 stated he/she has not seen a staff neglect a resident that may have caused a pressure injury. Staff give residents proper care and turn residents who are bed bound every two hours to avoid rashes. S4 stated R1 is aggressive and says something inappropriate, pinches and taps staff. S4 stated it does not hurt but for the most part R1 is nice. S4 stated that as caregivers they do body checks and if they see something that was not there before, they report to the MT on duty. For any life threatening situation they call 911. ---- page 2 of 4 On 02/05/26 LPA Partoza interviewed RP. RP stated that he/she visits R1 at least 3 to 4 times a week. RP stated that R1 is declining rapidly, does not want to eat or drink. RP stated that he/she was at the facility a lot and does not know how he/she missed the wound on R1s heel. RP stated what upset him/her was that he/she saw there was puss and blood coming out of R1s heel. RP stated he/she felt bad, R1 had the slip on “crocs” and saw there was liquid on R1s shoes for 2 days. RP stated, “he/she thinks it’s been going on for more than a week; it was not addressed that’s why it got bad so fast.” RP stated he/she cannot speculate how R1 sustained the pressure injury because he/she is not at the facility 24/7. RP stated "the reason they (staff) gave me was that R1 hit his/her heel on the wheelchair." RP stated that he/she was notified by staff regarding R1s pressure injury on 08/28/2025. RP stated the week before, R1 did not have socks on and after a week went by, it went from a small wound to a pressure injury, and when RP saw the wound next (08/28/25) it was already a pressure injury. RP stated, “I was just kind of shock that former MCD were cleaning R1s wound in the dining room.” RP stated that three (3) people give care to R1. On 02/05/2026, LPA interviewed 2 staff (S5 & S6) S5 stated that R1 is okay. R1 has dementia and sometimes R1 is nice sometimes not. S5 stated he/she saw R1 with the wound on his/her left heel. S5 stated he/she does not know how R1 got that injury. S5 stated "I report the problem to the med tech." S5 stated he/she does body checks on R1 before showering. S5 stated. It was probably 3 months or more ago that I observed the wound on R1s heel. I tried to give R1 a shower when I saw the wound for the first time. I was scared, I saw the problem, I saw blood on the heel and liquid coming out. I gave him/her a shower, and I reported to the MT on duty. Then I went back to do my other assignments.” S6 stated, “yes, I did see R1 with a wound on his/her left heel. I first saw it was around October or September and I saw fluid leaking from his/her heel. It was reported by S5. I notified R1s responsible party (RP), his/her PCP and our former MCD." S6 stated, he/she remembers calling 911 and R1 was taken by 911. S6 stated he/she does not know how R1 sustained the wound. S6 stated that former MCD came and looked at R1s wound and does not remember what MCD did next. S6 stated “At that time, R1 was not under hospice care; hospice began after R1 returned from the hospital.” S6 described R1 as able to move the upper body but not the lower body, rarely moving his/her legs, and usually sleeping on his/her back. S6 believed the injury was due to immobility. page 3 of 4 Based on document and record review, R1 was admitted to the facility on 09/20/2023. R1’s medical assessment dated 03/13/2025, stated that R1 exhibits aggressive behavior when getting out of bed. R1 is non-ambulatory due to both physical and cognitive conditions. R1’s individual care plan, dated 07/17/2025, specifies that during showers, R1’s wound should be cleaned with warm water, avoiding scrubbing, then gently patted dry. Staff are instructed to notify the medication technician (MT) or nurse to rewrap or redress R1’s foot. When transferring R1, staff must exercise caution with R1’s feet and ensure both legs are elevated every two hours. If R1 expresses discomfort, staff must notify the nurse or MT on duty immediately. R1 requires assistance from two staff members for transfers. Medical records indicate R1 is diagnosed with depression, dementia with behavioral disturbance, hypertension, and chronic osteoarthritis. On 08/24/25, R1 pulled a staff member’s hair during assistance with activities of daily living (ADLs). On 08/27/25, R1 exhibited a lack of appetite and was continuously monitored. On 08/28/25, at approximately 0800 hours, Care Staff (S5) informed S6 that R1 was observed with pink and white fluid on the left heel prior to showering. S6 photographed the heel, and notified R1’s responsible party (RP), primary care physician (PCP), and the facility’s former Medical Care Director (MCD). On 08/29/25, R1 was evaluated at Stanford Health Care, accompanied by RP, and diagnosed with cellulitis of the lower leg, an open wound on the left heel, a Stage 1 pressure injury on the right heel, tinea pedis (athlete's foot) on both feet, and dementia with behavioral disturbance. The report noted that R1 has no appetite for four days and demonstrated increased aggressive behaviors, including agitation while seated in a wheelchair. On 09/05/25, RP initiated hospice admission for R1. Based on record review and interview, 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 that resident sustained pressure injury due to neglect and lack of supervision and facility did not seek timely medical attention for resident's pressure injury are unsubstantiated. No deficiencies were cited during today's visit. An exit interview was conducted with ED Karina Nevarez and a copy of the report was provided. page 4 of 4 --- end of reportthe state’s words, verbatim · CDSS document, Feb 24, 2026 · control 26-AS-20250902144233

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced case management - other visit and met with Executive Director/Administrator (ED/ADM) Karina Nevarez. LPA stated the purpose of the visit. On January 14, 2026, the department received a report from Adult Protective Services (APS) and law enforcement, regarding self neglect by a resident (R1) who stated that he/she wanted to harm himself/herself. R1 was taken to the hospital by law enforcement (LE) and placed on 5150 hold. During today's visit, LPA requested for the following documents Physician's report (LIC 602), appraisal needs and services or individual service plan for R1. Based on document review, on January 16, 2026 the department received the incident report from the facility stating that R1 wanted to harm himself/herself and was taken to the hospital by LE. LPA conducted an interview with ED/ADM. ED/ADM stated that R1 has been at the facility for two months. ED/ADM stated that during R1s behavioral episode staff were present to ensure R1s safety. ED/ADM stated that staff tried to redirect R1, however, R1 refused to go back inside the facility. When LE arrived at the facility, R1 stated to LE that he/she wanted to harm himself/herself and was taken by LE to the hospital. ED/ADM stated after R1s hospitalization, R1 was transferred to a facility with a memory care vacancy. At this time, this case in under review and department will conduct a follow up visit, if warranted. No deficiencies were cited during today's visit based on California Code of Regulations (CCR) Title 22 and copy of the report was provided to ED/ADM Karina Nevarez.the state’s words, verbatim · CDSS document, Jan 27, 2026

Allegation investigated: Staff do not maintain facility elevators in good repair

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with the Senior Executive Director, Karina Nevarez and stated the purpose of today’s visit. On 8/13/2025, the Department received a complaint with the above allegation. On 8/21/2025, the Department conducted an initial investigation at the facility. On 8/13/2025, two residents were stuck in the elevator due to elevators not being in good repair. On 8/21/2025, LPA Rai interviewed 3 staff (S1-S3). 3 Out of 3 staff stated the facility elevators did have issues, but the facility management team did respond in a timely manner to ensure the elevators were evaluated by a professional technician. Continuation on LIC 9099-C, Page 1 of 2. Unsubstantiated Page 2 of 2. S1 stated on 8/13/2025, when the incident occurred, the staff ensured the residents were safe and then called the elevator company. S1 stated the technician assessed the problem and it was a new issue with the elevator, so they were able to fix and the residents were able to use the elevator within 24 hours. Three out of three staff stated it was the first incident where this elevator had issues and did not work, but the issue was resolved within 24 hours. On 8/21/2025, LPA Rai interviewed 10 residents (R1-R10). 2 Out of 10 residents stated they used the elevators a few minutes prior to the incident on 8/13/2025 and they did not see an issue to be reported to staff. 6 Out of 10 residents stated they were not aware of the incident on 8/13/2025 and the incident did not impact their day-to-day activities, which include meals, medication and activities. 10 Out of 10 residents stated they have no issues with facility not maintaining the facility elevators. R6 stated there is always one working elevator for residents to use. R10 stated the facility staff will notify the residents where the elevators are out of service for repairs or routine maintenance. LPA Rai reviewed documents related to the elevator’s maintenance and service. Based on review of document of the facility elevators from 7/1/2025 – 8/19/2025, there were 7 incidents recorded of the elevator technician coming to the facility and inspected and repairing the elevators. 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 Senior Executive Director, Karina Nevarez and a copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 12, 2025 · control 26-AS-20250813110545

Allegation investigated: Staff are not providing assistance to resident as necessary.

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to deliver the finding of the above allegation. LPA met with Executive Director, Val Baldugo-Macasieb. On 05/13/2025, the Department received the complaint. On 05/20/2025, the initial complaint investigation was conducted. The following documents were obtained for this investigation to include 3 resident’s physician’s report, service plans, long term care insurance paperwork and 1 resident’s admission agreement. It was alleged by the reporting party (RP) that the staff are not providing assistance in filing a resident’s (R1) long-term care insurance as necessary as the facility continually failed to provide the required documentation to R1’s long-term care (LTC) company resulting in a delayed reimbursement for R1. Page 1 of 3. Unfounded The review of records showed that the LTC insurance company has sent a letter to R1/R1’s responsible party advising of not receiving certain documents on 01/21/2025 and 05/02/2025. In the letter dated 05/02/2025 that was sent to R1's responsible party's address, it states that on 04/09/2025, 05/18/2025, and 05/27/2025 the LTC company requested but did not receive certain information in order to continue processing the claim. On 05/15/2025, the RP states that facility acted upon the issue and reached out to R1’s LTC insurance. 2 staff members (S1 – S2) were interviewed. S1 started his/her position in mid-February 2025 and S2 started his/her new position in late February – early March 2025. Based on interview, S1 stated that typically the facility would be informed by the resident’s responsible party if the LTC insurance company is missing forms, as the LTC insurance company communicates directly with the resident and/or responsible party. S1 and S2 states that they were only informed that R1’s LTC insurance company was missing forms on 05/13/2025 by R1’s responsible party. S1 and S2 denied being informed in March or April, that R1’s LTC insurance company was missing forms. S1 stated to have only received an email from R1’s responsible party regarding issues with the LTC insurance on two occasions, which was on 05/13/25 and sometime last year. It was stated that upon receiving the email from R1’s responsible party on 05/13/2025, the facility immediately sent the required form to the LTC insurance company and followed up with the LTC insurance company as well to confirm receipt. Based on interview, 2 out of 2 staff members thought it was the facility’s responsibility to submit all forms to the resident’s LTC insurance companies. Page 2 of 3. Upon following up with the facility’s regulatory team on 05/20/2025, S1 confirmed that it is actually not the facility’s responsibility to submit the forms to the LTC insurance company. It was stated that facility was filing the resident’s LTC insurance as courtesy to the resident, as this service is not indicated in their admission agreement or included in service plan. It was stated that the facility will continue to assist in filling out necessary forms such as the care needs assessments and monthly residence form, however it is the resident or resident’s responsible party to submit all necessary forms to the LTC insurance afterwards. 8 staff members who were interviewed all denied R1’s care ever stopping despite issues with R1’s LTC insurance. 8 out of 8 staff stated that R1 was always provided assistance with care. Based on review of R1’s admission agreement and service plan, the service of the facility filing R1’s LTC insurance is not written in the admission agreement or service plan. As per the RP, the service of filing R1’s LTC insurance was offered as from a discussion when R1 first moved in. On 08/08/2025, the facility's process when it comes to residents LTC insurance is to continue to work with the resident and/or resident's responsible party on completing forms required by the facility to fill out. However, the resident and/or resident's responsible party's is now responsible in sending the paperwork(s) to the LTC insurance. The Department has investigated the above allegation. Based on interview, record review and observation the above allegation is unfounded, meaning the allegation is 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, Val Baldugo-Macasieb and a copy of the report was provided. Page 3 of 3.the state’s words, verbatim · CDSS document, Aug 8, 2025 · control 26-AS-20250513093103

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct a case management – incident visit. LPA met with Business Office Director, Frank Lim. The purpose of the visit is to follow-up on a SOC-341 the Department received on 07/10/2025 regarding a video that was posted on a social media app of a resident (R1) who was being mistreated by his/her authorized representative in a public setting. During visit, documents were obtained for this case management to include R1's POA (power of attorney) documents, physician's report, pre-placement appraisal, individual service plan, progress notes, and behavioral expression appraisal. 7 staff members were interviewed. Based on staff interviewed, 7 out of 7 staff members denied any knowledge or observations of R1's authorized representative physically, verbally, mentally, and emotionally abusing R1 while in the community or outside of the community. 7 out of 7 staff members denied the observation or knowledge of R1's authorized representative mistreating R1 in the community and outside of the community. 6 out of 7 staff member stated that R1 has never mentioned any negative comments or experiences with his/her authorized representative. 1 out of 7 staff members stated that R1 has called his/her authorized representative "mean" but R1 did not go into specific examples or details as to how his/her authorized representative is mean. Page 1 of 2. Based on interview with R1, it was stated that he/she informed 2 staff members that his/her authorized representative was mean but R1 did not go into the detail about the specific statements shared with the 2 staff members to include who, what, when, where, and how. These 2 staff members were interviewed, who both denied R1 mentioning any mistreatment or negative experiences with his/her authorized representative to them. To ensure the resident's safety, the facility has implemented frequent checks for R1 throughout the day. This incident was cross reported to other agencies for further investigation. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with BOD Frank Lim and a copy of the report was provided. Page 2 of 2.the state’s words, verbatim · CDSS document, Jul 15, 2025

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management - Annual Continuation visit and met with Executive Director Val Baldugo-Macasieb. The visit was a continuation of the annual inspection visit that occurred on 04/22/2025. During visit, LPA Marrufo reviewed staff and resident records. LPA reviewed 7 resident records, including Centrally Stored Medication and Destruction Records, and found them to be complete. LPA reviewed 7 staff records and found them to be complete. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Executive Director Val Baldugo-Macasieb and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, May 13, 2025

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Maria (Mita) Partoza, conducted an unannouced case management - deficiencies vist and met with Executive Director / ADM (ED/ADM) Val Baldugo-Macasieb and stated the purpose of the visit. On 6/14/2024, the facility was cited and have submitted a plan of correction. LPA observed that the facility, installed a wander guard alarm system and bracelet are given to residents who were diagnosed with an early on set of dementia and resides in the Assisted Living. Based on observation, ED/ADM demonstrated how the alarm works and LPA observed that it is functioning. All exit and fire doors have the wander guard alarm. LPA observed staff are present at all times in the reception area and have residents sign in and out prior to exciting the facility. ED/ADM stated that staff are at the front desk from 8:00 a.m. to 8:00 p.m. After 8:00 p.m. all doors are locked a door bell is provided if any of the residents or family member arrives late or come in after hours. No deficiencies were cited during today's visit based on CCR Title 22. An exit interview was conducted with ED/ADM Val Baldugo-Macasieb and a copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 22, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced required 1 year inspection and met with facility Executive Director/Administrator (ED/ADM) Val Baldugo-Macasieb and stated the purpose of the visit. The facility serves age 60 and over, 140 non-ambulatory, 21 may be bedridden and hospice waiver for 15. LPA toured the interior of the facility, including entryway, common room, dining room, kitchen and food storage, laundry room, resident bedrooms, bathrooms, medicine room, and activities room, Assisted Living and Memory Care area of the facility. All emergency exits are clear from obstruction. Facility has activities scheduled posted for the whole month. LPA observed residents participating during activity time. LPA observed water in the hallway restroom are regulated to deliver water temperature that is not too hot nor too cold. The water temperature measured from 118 to 120 degree F. Memory Care exits are equipped with delayed egress and working audible alarms. LPA observed rodent traps under the counter in the Memory Care unit. The kitchen is equipped with commercial grade refrigerator and freezer and doors to the kitchen have locks when not in used and are not accessible to residents. LPA observed emergency drinking water supply, 2 days of perishable food and 7 days for non-perishable food. The facility has snack bars in the activity areas. The facility is equipped with fire alarm and carbon monoxide alarm system that alerts the fire department. The facility has fire extinguishers that were last inspected in May and June of 2024. continued to LIC 809C page 2 The residents room have sufficient and ample storage for the assisted living and memory care units. Rooms were observed to be sanitary and organized. The facility has fire and disaster drill training that was administered on 2/21/2025 by Fire Safety Service, Inc. The facility maintains Ecolab to monitor and exterminate possible pest in the Memory Care Area. ED/ADM stated Ecolab comes to the facility each month and or as needed to monitor the traps set at the Memory Care kitchen area. Due to time constraint the required 1 year annual inspection will be continued at a later date. No deficiency was cited during today's annual required visit. An exit interview was conducted with Executive Director/ Administrator Val Baldugo Macasieb and a copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 22, 2025

Allegation investigated: Staff did not administer resident's medication as prescribed. Staff did not seek medical attention in a timely manner.

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit and met with Business Office Director (BOD) Val Baldugo Macasieb. On 3/6/2024, the Department received a complaint with the allegations that staff did not administer resident's medication as prescribed and staff did not seek medical attention in a timely manner. On 3/12/2024, the Department conducted an initial investigation visit. LPA interviewed Executive Director (ED) and Resident Service Director (RSD). LPA requested copies of R1's resident records, including R1's Physician's Report, R1's Needs and Services Plan, R1's PRN Authorization Letter, R1's MARs, and R1's Progress Notes. Continue on LIC9099-C. page 1 of 3. Unfounded Staff did not administer resident's medication as prescribed: The allegation is that the facility did not administer resident R1's PRN medication to R1. On 3/12/2024, LPA interviewed Executive Director (ED) Karina Nevarez. ED stated resident R1 is a resident in memory Care Unit, and is under hospice care. ED stated the medication that did not administer to R1 is PRN medication meaning to administer to resident as needed. ED stated the symptoms R1 had were related to the Hospice diagnosis. ED stated the staff called R1's hospice agency for advice. ED stated R1's hospice agency had given the approval for the R1's family member (FM) to carry R1's PRN medication and to administer the medication as need. LPA interviewed Resident Service Director (RSD). RSD stated resident R1 is under hospice care. RSD stated the protocol for resident who is on hospice care and having symptoms related to the hospice diagnosis is to call hospice nurse for advice. RSD stated on 2/17/2024, R1 had the symptom of chest pain which is the symptoms related to R1's hospice diagnosis. RSD stated the facility staff contacted hospice nurse and Hospice nurse arrived at the facility at approximately 6:00PM on 2/17/2024. Based on the review of R1's physician report, R1 is on hospice care. Based on the review of R1's Individualized Service Plan, R1's has Special Medical Needs that R1 requires service from hospice staff. Based on the interview and records reviewed, R1 was under hospice care. R1 had the symptom same as R1's hospice diagnosis. The facility staff are not allowed to administer R1's PRN medication to R1. The facility staff need to call hospice care nurse for advice. Staff did not seek medical attention in a timely manner: The allegation is that resident R1's family member (FM) called a facility staff that R1 needed PRN medication when R1 had pain, but it took around 37 minutes to get the PRN medication. Continue on LIC9099-C. Page 2 of 3. On 3/12/2024, LPA interviewed Executive Director (ED) Karina Nevarez. ED stated resident R1 was under hospice care. ED stated during the incident, the symptoms R1 had were related to R1's Hospice diagnosis. ED stated the staff need to call R1's hospice agency for advice first. ED stated the staff received FM's call, actually was busy at another building and was having an emergency situation which needed to finish first. ED stated S1 went to R1 after the facility received R1's hospice care nurse's advice and after S1 finished the situation of emergency. ED stated R1's hospice agency had given the approval for the R1's family member (FM) to carry R1's PRN medication and to administer the medication as need. LPA interviewed Resident Service Director (RSD). RSD stated resident R1 is under hospice care and R1's symptom was same as R1's hospice diagnosis. RSD stated by protocol, the facility should contact R1's hospice care nurse for advice. RSD provided the text messages log with R1's family member (FM), Med Techs, and R1's hospice care nurse. RSD denied the facility staff neglect. RSD stated the facility staff were processing R1's situation during the incident. Based on the review of R1's physician report, R1 is on hospice care. Based on the review of R1's individualized Service Plan, R1's has Special Medical Needs that R1 requires service from hospice staff. Based on the review of RSD text messages logs with FM, facility Med Techs, and R1's hospice care nurse. The facility staff were seeking medication attention for R1. The Department has investigated the above allegation. Based on the investigation, document reviewed, and interviews conducted, the Department found that the above allegation is UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. No citations noted at today’s compliant investigation visit. Exit interview conducted with BOD. This report was provided to review and for signature. A copy of this report was provided to BOD.the state’s words, verbatim · CDSS document, Nov 15, 2024 · control 26-AS-20240306095915

Type of visit: Case Management - Incident

On 8/27/2024 at approximately 1:58 p.m. , Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced case management visit regarding an incident report that was received by the department on 8/23/2024 involving a resident. LPA met with Executive Director/Administrator (ED/ADM) Karina Nevarez and LPA stated the purpose of the visit. LPA conducted a file review and requested copies of the resident's file including but not limited to admission agreement, medication list, physician's report, appraisal needs and services plan, incident report and background history. No deficiency cited during today's visit. Due to insufficient information this case management will remain open until further investigation.the state’s words, verbatim · CDSS document, Aug 27, 2024

Allegation investigated: Staff are not answering resident call buttons timely due to insufficient staffing. Residents are not receiving at least 3 meals a day. Residents are not receiving meals timely. Thermostat in resident's room is in disrepair.

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation findings and met with Business Office Director (BOD) Val Baldugo. On 06/10/2022, the Department received a complaint with the above allegations. On 06/17/2022, the Department conducted an initial investigation visit. LPA interviewed 2 staff and 3 residents. LPA requested the rosters of residents and staff, call button logs, and work order log. Continue on LIC9099-C. Page 1 of 4. Unsubstantiated Staff are not answering resident call buttons timely due to insufficient staffing: On 06/17/2022, LPA interviewed 2 staff. Both stated the facility was actively hiring staff. Both stated the facility just had the management team change. 1 out of 2 staff stated the facility's basic operation has no problem, because staff were working overtime to meet residents' needs. 1 out of 2 staff stated the facility staff respond to the call buttons around 10 minutes. LPA interviewed 3 residents. 2 out of 3 stated it takes 10 to 20 minutes for staff to come to help when they pressed the call button for help. 1 out of 3 stated he/she had two times experiences that the staff's response time were longer than one hour when he/she pressed the call button for help, but other than that the staff's response time were within reasonable time. LPA requested the facility call button logs, the facility was unable to provide for that time period. On 05/23/2024, LPA interviewed 9 residents. 2 out 9 residents stated they have call button but they never used the call buttons. 7 out 9 residents stated the facility staff respond to the call buttons between 1 to 15 minutes. Based on the interviews, there is no evidence to indicate the facility staff are not answering resident call buttons timely due to insufficient staffing. Residents are not receiving at least 3 meals a day: Residents are not receiving meals timely: On 06/17/2022, LPA interviewed 2 staff. Both stated the facility dinning room opens from 7:00AM to 7:00PM every day to provide breakfast, lunch, dinner and snack. Both stated the facility provides room service for meals and the caregivers delivers the meals to resident rooms. LPA toured 6 resident rooms with staff and interviewed residents. 3 out of 6 stated they go to the dining room for breakfast, lunch, and dinner, they did not have any complaint for the meal service. 2 out 6 just finished the lunch, and just wanted to take a nap and refused to get interview. 1 out of 6 resident was unable to talk, staff stated he/she already finished lunch. Continue on LIC9099-C. Page 2 of 4. On 5/23/2024, LPA interviewed 9 residents. 3 out 9 residents stated they go to the dining room for breakfasts, lunches and dinners during the meal time. 5 out 9 stated they have breakfasts, lunches and dinners delivered to their room during the meal time. 1 out 9 stated he/she go to the dining room for breakfasts and lunches during the meal time, and the dinners were delivered to his/her room during the dinner time. Based on the interviews, no evidence to indicate that residents did not receive 3 meals a day and no evidence to indicate residents are not receiving meals during the meal time. Thermostat in resident's room is in disrepair: On 06/17/2022, LPA interviewed 2 staff. Both stated the facility air condition was not working fine several days ago, but it was fixed. LPA interviewed resident R1. R1 stated his/her room air condition was not working several days ago, but it was fixed. LPA requested the work orders for the air condition, the facility was unable to provide. On 5/23/2024, LPA interviewed staff S1. S1 stated some residents sometimes maladjusted the thermostat accidentally and thought the air condition was not working. S1 stated if residents found maintenance staff around, then maintenance staff can fix it immediately. S1 stated if the residents asked caregivers to file a work order, and it usually will take one day to fix. S1 stated it will take longer if it needs to replace the parts depending on how soon the parts are available. S1 stated it usually takes around 3 days if needs to replace the parts. S1 stated from year 2022, the facility has upgraded the thermostats/air conditions and the system should be fine now. S1 stated the facility provides fan to the resident if the resident's room thermostat/air condition does not work. LPA interviewed 9 residents. 9 out of 9 residents stated air conditions are working fine. 1 out of 9 residents stated he/she heard one resident's air condition was not working but was fixed within 3 days. Continue on LIC9099-C. Page 3 of 4. Based on the interviews, most of the residents' room conditions/thermostats are working fine. Resident R1's thermostat/air condition was not working but was fixed within reasonable time period. One resident stated he/she heard one resident's air condition/thermostat was fixed within three days. The facility provides fan to resident if the resident's room air condition does not work during the repair time period. Based on investigation, observations, 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 citations noted at today’s compliant investigation visit. This report was provided to BOD for signature. A copy of the report was provided to BOD. Page 4 of 4.the state’s words, verbatim · CDSS document, Jul 9, 2024 · control 26-AS-20220610142646

Allegation investigated: Facility has insufficient staffing.

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation finding and met with Business Office Director (BOD) Val Baldugo. On 06/17/2022, the Department received a complaint with the allegation that the facility has insufficient staffing. On 06/23/2022, the Department conducted an initial investigation visit. LPA interviewed 4 staff and 2 residents. LPA toured the facility. Continue on LIC9099-C. Page 1 of 2. Unsubstantiated Facility has insufficient staffing: On 06/23/2022, LPA interviewed 5 staff. Staff S1 stated the facility is actively hiring more staff. S1 stated there were 1 nurse, 5 caregivers, 1 Med Tech, a leader of Med Techs/caregivers group, 3 cooks, 3 servers, 3 house keepers and 1 laundry staff on duty. S1 stated the facility had a management team change recently which causes some staff left the jobs. S1 stated there are 9 applicants under the process of hiring and will be on board soon. S1 stated a new Executive Director will be on board next month. LPA interviewed 3 staff. 2 out of 3 staff stated the facility does not have staffing issue. 1 out of 3 staff stated the facility could hire more staff. LPA toured 3 resident rooms and interviewed 2 residents and one family member of resident. 2 out of 3 stated the facility's basic operation has no problem and the residents receive the cares they need. 1 out 3 stated the facility should hire more staff. On 5/23/2024, LPA interviewed 7 staff. 6 out of 7 stated there are 8 caregivers, 2 Med Tech, 1 leader of Med Tech/caregivers group and 1 nurse on duty, and they all think the facility does not have insufficient staffing issue. LPA interviewed 9 residents. 8 out of 9 residents stated the facility does not have insufficient staffing issue. 1 out of 9 residents stated the facility can hire more staff. Based on the interviews with staff and residents and records reviewed, no evidence ti indicate the facility has insufficient staffing. Based on investigation, observations, 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 citations noted at today’s compliant investigation visit. This report was provided to BOD for signature. A copy of the report was provided to BOD. Page 2 of 2.the state’s words, verbatim · CDSS document, Jul 9, 2024 · control 26-AS-20220617121040

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced case management visit in regards to a phone call the Department received regarding R1 on June 14, 2024. LPA met with Health Services Director (HSD) John Doyle and explained the purpose of the visit. On June 14, 2024, the Department received a phone call from facility Administrator (ADM) Karina Nevarez who stated resident R1 was discovered missing on June 13, 2024 around 9:30pm. ADM stated that R1 was admitted to the facility on March 2024. ADM stated R1's secondary diagnosis is early onset of dementia. ADM stated that the resident likes to sit by the front but is always redirected back. ADM stated R1 resides in the assisted living section of the facility. ADM stated when staff were asked, no one saw R1 leave the facility and have knowledge which door was used by R1 to leave the facility. ADM stated that the family has been notified. ADM stated that SJPD with some facility staff were actively searching for the resident since yesterday and SJPD issued a SILVER ALERT (missing person). The Department received a follow up call from the facility ADM, stating the resident was found was in the hospital since the night before, at 12:10am. ADM stated R1 used the front door and walked to the shopping center near the facility. ADM stated the store clerk contacted 911, when R1 was unable to answer questions about where he/she lived and his/her name. ADM stated R1 stayed in the hospital overnight. ADM stated R1 was going to be transferred to memory care, but they do not have any availability. On June 14, 2024, LPA interviewed HSD. HSD stated the facility has 11 residents with dementia living in the assisted living section of the facility. HSD stated when R1 first moved in he/she would wander to the front or wander up and down the halls. HSD stated once R1 got new friends and joined activities, the wandering went down. Page 1 Out of 2. Based on a review of R1's physicians report dated August 28, 2023, R1 has dementia and cannot leave the facility unassisted. A review of R1's Preplacement Appraisal states R1 has dementia. Under "needs special observation/night supervision (due to confusion, forgetfulness, wandering)", the preplacement appraisal has a question mark between the unchecked yes and no box. Based on a review of R1's progress notes; R1 was noted to pace the floors on May 15, 2024. R1's Progress notes also states R1 was "wandering the halls" on May 16, 17, & 18. A review of R1's Needs and services plan, dated April 1, 2024, under elopement risk status, the form states R1's elopement risk will be evaluated. A review of R1's Elopement Risk Assessment, dated March 28, 2024 states R1 is not able to leave the facility unassisted. An immediate civil penalty of $500.00 is being assessed against the facility today for violation the absence of supervision, which resulted in R1 eloping from the facility overnight. Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D. This report was reviewed with Health Services Director John Doyle and a copy of the report was provided. Appeal Rights was provided. END OF REPORT Page 2 Out of 2.the state’s words, verbatim · CDSS document, Jun 14, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Jun 15, 2024

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)(4) To care, supervision, and services that meet their individual needs ... by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by; Based on interviews conducted, resident R1 had elopped from the facility on June 13, 2024 and staff did not provide R1 with Care and Supervision to met his/her needs. This poses an immideate threat to health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 14, 2024

Plan of correction: ADM stated she will conduct training for her staff regarding wandering residents and elopement. ADM stated she will send documentation of training to LPA by POC date, June 15, 2024.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87705(b)(2) · Plan of correction due date: Jun 15, 2024

87705 Care of Persons with Dementia (b)In addition to the requirements as ... the plan of operation shall address the needs of residents with dementia, including:(2) Safety measures to address behaviors such as wandering, .... This requirement was not met as evidenced by; Based on interviews conducted, licensee did not have plan of operation and safety measures to address the needs of R1 who is diagnosed with dementia and eloped from facility while living in assisted living unit, was supposed to be admitted in dementia unit.the state’s words, verbatim · CDSS document, Jun 14, 2024

Plan of correction: ADM stated she will submit a plan of action on how she will ensure residents with dementia and wandering behaviors who are residing in Assisted living will be kept safe from eloping from the facility.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(d)(2) · Plan of correction due date: Jun 15, 2024

87405 Administrator Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)... (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement is not met as evidenced by: Based on records reviewed and interviews conducted, Administrator did not exhibit the knowledge of applicable laws, rules and regulations resulting in serious violations involving a resident who eloped from facility which poses an immediate health safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 14, 2024

Plan of correction: ADM stated she will send a letter of understanding regading the regulation. ADM stated she will send the letter by POC date, June 15, 2024.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced required annual inspection and met with facility Administrator (ADM) Karina Nevarez. The facility's censis is 124 residents and 77 staff. LPA toured the interior of the facility, including entryway, common room, dining room, kitchen, laundry room, resident bedrooms, bathrooms, medicine room, and activities room. LPA toured the exterior of the facility and observed all walkways are free from obstruction. LPA observed the following there were no prohibited items observed in the resident rooms. All emergency exits are clear from obstruction. Facility has activities scheduled posted for the whole month. LPA observed residents participating during activity time. LPA observed staff assisting residents in the dining room and are present on the hallways to give assistance to residents. LPA tested the facility water temperature. Water temperature measured between 112 to 116 degree Fahrenheit. LPA observed sufficient supply of food, 2 days of perishable food and 7 days for non-perishable food. Fire extinguisher was last inspected on 05/15/2023. All toxins are kept in a locked room. Knives are locked and is not accessible to residents. Carbon monoxide alarms are placed in the hallways and each apartment unit. The room temperature is at 70 degrees F. Skid matts and grab bars in the bathrooms. continued to LIC 809C page 2 LPA reviewed the facility record and observed that the fire alarm is maintained and serviced by Fire Safety Service Inc. and the company provides simulation training to facility staff for different shifts. The fire alarms system for the entire building was tested on 3/1/2024 and 3/18/2024 and found to be in good working conditions. LPA reviewed resident's record and observed no deficiency, record is complete and updated. LPA reviewed the facility staff record and observed that record is up to date including staff training. LPA review the centrally stored medication and destruction record (CSMDR) and found the record to have sufficient information. LPA conducted advisory assistance for future record keeping regarding dates started and expiration dates on the CSMDR. No deficiency was cited during today's visit annual required visit. An exit interview was conducted with Executive Director Karina Nevarez and a copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 24, 2024