Lake Park Senior Living

Type of visit: Case Management - Other

On 07/22/2026 at approximately 11:00am, Financial Analyst (FA) Arne Bracchi arrived at the facility unannounced and requested to meet with Executive Director Kirsten Korfhage. She was in training, so Business Office Manager (Manager) Fouzia Yaagoub was made available. FA requested and received a resident roster. A copy of the current resident contract could be made available via an e-mail request. Manager explained that an additional level of care (designated as “Apartment”) is offered to potential residents. This contract does not include services or amenities such as care, meals, transportation or housekeeping. FA mentioned the “inactive” status of the Certificate of Authority (COA) due to unsubmitted annual reports for the years ended 2024 and 2025. Manager said financials are compiled at their corporate office. Manager mentioned she has recently been asked by a corporate representative to assist in completing the Disclosure Statement with community data. FA then requested a tour of the CCRC to ensure all postings and required documents were accessible to residents and visitors. This included ascertaining if the COA is listed and/or displayed in the hallway bulletin board, library or elsewhere. Manager led FA on a tour of the community, which included the viewing of the Fellowship room, a vacant apartment, two libraries and common areas. As a result of today's visit, no compliance issues pursuant to the Continuing Care Contract Statutes were cited. FA follow up with an email and summary provided to the Manager within seven days of visit. Manager said she will e-mail the requested copies of current resident contract and resident handbook. Exit interview conducted with Manager. FA told Manager he would document today’s visit via a completed Licensing form number LIC 809 upon return to the office and would e-mail the 809 to ED for signature.the state’s words, verbatim · CDSS document, Jul 22, 2026

Type of visit: Case Management - Other

On 04/28/2026 at 2:30 PM, Licensing Program Analyst (LPA) David Doidge arrived unannounced to deliver an amended report for a complaint dated 12/09/2025. LPA met with Executive Director Kirsten Korfhage and explained the purpose of the visit. Amended 9099 to remove an allegation not worked on by LPA. No deficiencies cited during the visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 28, 2026

Allegation investigated: Staff did not ensure residents apartment was fixed timely Staff did not assist resident with moving apartments due to water damage Staff didn't ensure leak was fixed properly

On 04/24/2026 at 09:45 AM, Licensing Program Analyst (LPA) David Doidge arrived unannounced to conduct an initial 10-day complaint investigation in regards to the allegations above. LPA met with Executive Directo Kirsten Korfhage and explained the purpose of the visit. During the course of the investigation, LPA interviewed S1, S2, R1 and attempted to speak with R2. LPA obtained copies of correspondence between R1’s Responsible Party (RP) and the facility, and an established timeline for the event that occurred. Allegation: Staff did not ensure residents apartment was fixed timely Investigation Findings: It was reported to the department that a cleaning woman reported to the victim that she had been in the unit after the flooding prior to April 8 and saw the water damage, but did not report it. LPA interviewed S4. S4 cleans R1’s room weekly on Wednesdays. Continued on LIC9099-C Unsubstantiated Continued from lIC9099 S4 entered R1’s room to find the floors buckled but dry. S4 informed LPA S4 did not say anything to staff as S4 did not know whether or not the floor issue had already been reported. S4 said the floor was dry and S4 did a light vacuuming and left the room. S4 informed LPA that R1 questioned S4 about the water damage, but did not know when it occurred and conveyed that to R1. R1 informed LPA that on April eighth R1 arrived home and saw the laminate floor was buckled and the front door was hard to open. R1 stated R1 waited until the next day, April 9th, to inform the facility staff of the damage. S1 informed LPA that that same day, April 9th, S3 went to R1’s room, saw the damage, and told R1 that the head of maintenance, S3, would be out to inspect and assess the damage on Monday the 13th. R1 confirmed that S3 came out on Monday the 13th to inspect and assess where the leak came from. S1 informed LPA that management determined the floor needed to be replaced and found R1 a temporary apartment to stay in that same day. S1 informed LPA that the facility has offered R1 a choice of eight apartments to move into, and R1 has selected a new apartment to move in to, with a move in day set for April 24th. LPA confirm with R1 that R1 has held off moving R1’s belongings into the new room until R1 feels ready to move in. LPA confirmed that R1 is staying in a temporary room as R1 is not ready to move into the new apartment. Based on interviews this allegation is UNSUBSTANTIATED. Allegation: Staff did not assist resident with moving apartments due to water damage Investigation Findings: It was reported to the department that the victim should move out and that the victim would need to personally pay for all of the moving expenses with no assistance being offered by the facility. W1 informed LPA that W1 had only heard initial remarks from R1 about R1 needing to move. W1 did not confirm that R1 said R1 would be expected to pay and was speculating based on how upset R1 was during their initial conversation. W1 did not have firsthand interactions with staff\ and informed LPA that those remarks were based on W1’s impression of W1 and R1's conversation. S1 informed LPA that staff have moved R1’s bed and a few furniture items to both the temporary apartment and later to R1’s new apartment. R1 confirmed that the facility did move R1’s bed and a few furniture pieces to both rooms. LPA inspected all three rooms to confirm items had been moved. R1 informed LPA that staff have spoken to RP and R1 about the move, and RP and S1 have sorted out the details. S1 stated RP will hire a moving company to move R1’s remaining items and will reimburse RP. R1 is currently waiting to have R1’s belongings moved until R1 is ready to move. Based on interviews and documented conversations, this allegation is UNSUBSTANTIATED. Continued on LIC9099-C Continued from LIC9099-C Allegation: Staff didn't ensure leak was fixed properly Investigation Findings: It was reported to the department that R1’s unit had flooded due to the negligence of the upstairs neighbor. W1 informed LPA that W1 thought R1’s apartment was flooded due to an upstairs neighbor flooding his/her’s room. S1 informed LPA that S3 had inspected both rooms and reported that the water damage was due to a faucet being left on in R2’s room. not due to a broken water pipe. LPA inspected both rooms and saw that there is water damage to both rooms, but no water flowing. LPA could not see an ongoing leak. R2 would not speak to LPA to confirm where or not R2 left a faucet on. S1 informed LPA that S3 determined the water damage in R1’s room came from a faucet in R2’’s room. Based on interviews and inspection, this allegation is UNSUBSTANTIATED. Based on interviews, inspection and record reviews conducted, the above allegations are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. No deficiencies observed or cited during this visit. Exit interview conducted and a copy this report was provided.the state’s words, verbatim · CDSS document, Apr 24, 2026 · control 15-AS-20260416105136

Allegation investigated: Elevator is in disrepair.

On 3/20/2026 at 10:45AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a complaint investigation and delivered findings in regards to the allegation above. LPA met with Executive Director, Kirsten Korfhage and informed her the reason for visit. During visit, LPA interviewed staff and obtained correspondence regarding elevator repairs. LPA observed elevator #2 is currently inoperable. Interview with staff revealed that elevator #2 broke down around December of 2024 and in July of 2025 there was a contract to replace all three elevators. A correspondence revealed that in November of 2025 the licensee was notified that a hatch need to be constructed for new elevator materials to be transported into the facility. Correspondence dated 3/2/2026 indicated licensee is in the planning phase of the hatch construction. (Continue on LIC9099C...) Substantiated There's no additional information provided for the hatch construction and the elevator replacement plan. Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation are found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D. Exit interview conducted. A copy of this report, civil penalty, and appeal rights provided.the state’s words, verbatim · CDSS document, Mar 20, 2026 · control 15-AS-20260313084413

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Apr 10, 2026

Maintenance and Operation. (a) The facility shall be clean, safe, sanitary and in good repair at all times... This requirement is not met as evidence by: Based on observation and record review, licensee did not comply with the section cited above by having elevator #2 in disrepair which poses a potential health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, Mar 20, 2026

Plan of correction: Executive Director (ED) has agreed to obtain a written detail plan on the process of the hatch construction and elevator replacements with completion dates for each step of the process. ED will submit the plan to CCLD by POC date. Civil penalty of $250 is being assessed for a repeat violation.

Type of visit: Case Management - Other

On 12/29/2024 at 12:50 PM, Licensing Program Analysts (LPA) David Doidge arrived unannounced to deliver an amended report for complaint 15-AS-20241030085123. LPA met with Executive Director, Kirsten Korfhage, and explained the purpose of the visit. LPA signed and printed the amended report. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Dec 29, 2025

Type of visit: Required - 1 Year

On 12/18/2024 at 11:45 PM, Licensing Program Analysts (LPA) David Doidge arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director, Kirsten Korfhage, and explained the purpose of the visit. LPA toured the facility including but not limit to, bedrooms, bathrooms, multiple activity rooms, kitchen, and common area. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 76.4 degrees Fahrenheit. The hot water temperature in a common bathroom was measured at 113 degrees Fahrenheit. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps are locked and inaccessible to residents in care. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 08/06/2025 Emergency disaster drills are conducted monthly, with the last one conducted on 12/02/2025. First aid kit was observed to be complete. LPA reviewed five (5) resident records and five (5) staff records, all were complete. No deficiencies observed or cited during this visit. Exit interview conducted and a copy of this report providedthe state’s words, verbatim · CDSS document, Dec 18, 2025

Allegation investigated: Staff do not have sufficient supplies to maintain resident hygiene or meet infection control requirements. Staff are not adequately trained Staff are not following reporting requirements Staff are not evaluating changes in resident's condition as required Staff do not address pest in the facility Staff do not provide adequate food service Staff do not ensure the facility is properly maintained

On 07/22/2025 at 11:00 AM, Licensing Program Analyst (LPA) David Doidge arrived unannounced to deliver findings for the allegations above. Upon arrival, LPA met with Executive Director, Kirsten Korfhage, and explained the purpose of the vest. During the course of the investigation, LPA conducted interviews with five (5) staff. LPA obtained and reviewed staff training logs, resident appraisals for five (5) residents, monthly statements from Clark Pest Control, the LIC500, and food service staff shift schedule, Allegation: Staff do not have sufficient supplies to maintain resident hygiene or meet infection control requirements. Investigation Finding: Based on staff interviews this allegation is Unsubstantiated. It was reported to the Department that the facility does not have sufficient supplies to maintain resident hygiene or meet infection control requirements. Continued on LIC 9099-C Unsubstantiated Continued from LIC9099 During interview with staff, LPA observed sufficient supplies in every department. Each department has a budget and uses Amazon Business to order supplies. Each department head has the task of ordering supplies on a monthly basis for the department he/she oversees. Orders are submitted and later approved by management, then supplies are delivered. If a department were to run low, or out of a supply, other departments will offer supplies until new supplies come in. Department heads also have access to a company credit card for emergency use. As long as staff go through the appropriate channels to order supplies, supplies get approved within a few days. Allegation: Staff are not adequately trained. Investigation Finding: Based on file review, training logs and staff interviews, this allegation is Unsubstantiated. Staff are adequately trained and detail logs of training are kept. Monthly all-staff meetings have different training provided. Staff are told in advance of when and what topics are going to be covered. Staff are also trained through Assisted Living Education (ALE) with records and certificates kept. Allegation: Staff are not following reporting requirements Investigation Finding: Based on staff interviews, death reports, and Unusual Incident Reports (UIRs) delivered to the department, this allegation is Unsubstantiated. Staff are required and encouraged to report any incidents and deaths to the Executive Director. Executive Director Kirsten Korfhage submits all reports to the department in a timely manner. LPA receives digital copies and the department retains copies. Allegation: Staff are not evaluating changes in resident's condition as required Investigation Finding: Based on record review and staff interviews, assessments of residents are being conducted. This allegation is Unsubstantiated. LPA reviewed and obtained copies of assessments for five (5) residents. Each resident had proper assessments. Previous record review from annual inspections also show resident assessments and evaluations were being conducted. Continued on LIC9099-C Continued from LIC9099-C Allegation: Staff do not address pest in the facility. Investigation Finding: Based on observation, staff interviews, and monthly statements form Clark Pest Control, this allegation is Unsubstantiated. LPA observed no signs of mold, rodent droppings or disrepair anywhere in the facility. The kitchen is clear of mold and other pests. Dishes are cleaned in a timely manner after use. Staff have admitted to finding cockroaches however, the facility has a contract with Clark Pest Control and all incidents are dealt with. Clark comes out on a weekly basis and treats any and all sightings of cockroaches reported. Allegation: Staff do not provide adequate food service. Investigation Finding: Based on interview with staff and staffing records, this allegation is Unsubstantiated. LPA observed food to be fresh and properly stored. LPA observed that there is sufficient staff for food service S4 reported that meal service may at times get backed up, but meals are still served with as limited delay as manageable. Allegation: Staff do not ensure the facility is properly maintained. Investigation Finding: Based on observation, staff interviews and Elevator Modernization Contract, this allegation is Unsubstantiated. LPA observed the Facility to be well maintained, with all areas kept clean, pest and mold free. Elevators have plans for modernization, with set repair dates. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations above do not meet Regulation Requirements are unsubstantiated. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 22, 2025 · control 15-AS-20250708151026

Allegation investigated: Licensee is not ensuring that facility elevator is maintained in good repair

On 06/19/2025 at 11:15 AM, Licensing Program Analyst (LPA) D. Doidge arrived unannounced to conduct an initial 10-day complaint investigation, and deliver findings for the allegation above. Upon arrival, LPA met with Executive Director, Kirsten Korfhage, and explained the purpose of the vest. Allegation: Licensee is not ensuring that facility elevator is maintained in good repair. Findings: LPA had previously interviewed staff and residents regarding the elevator. Based on observation and interviews, elevator two has been out of service since November. Despite efforts made by management to get the elevator repaired, it remains nonoperational. Therefore, the allegation above is SUBSTANTIATED. Continued on LIC9099-C Substantiated Continued form LIC-9099 Based on interviews and observation, the preponderance of evidence is met, therefore, the allegation is substantiated. Deficiency is cited from Title 22 California Code of Regulations and listed on LIC9099-D. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result civil penalty. *An immediate Civil Penalty of $250 is being assessed on today's date for a repeat violation* Deficiency plan and proof of correction were discussed with ED.. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Jun 19, 2025 · control 15-AS-20250617153955

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jun 19, 2025

87303 Maintenance and Operation (a) The facility shall be ...in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by: Based on observation the Licensee did not comply with the section cited above in having elevator in disrepair, which posed an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jun 19, 2025

Plan of correction: Executive Director agreed to by July third to update LPA with an updated date as to what the issues witht eh elevator to get a clear repair date. *An immediate Civil Penalty of $250 is being assessed on today's date for a repeat violation*

Allegation investigated: Licensee is not ensuring that facility elevator is maintained in good repair.

On 04/22/2025 at 11:10 AM, Licensing Program Analyst (LPA) D. Doidge arrived unannounced to deliver complaint findings for the allegations above. Upon arrival, LPA met with Fouzia Yaagoub, Business Office Manager. Allegation: Licensee is not ensuring that facility elevator is maintained in good repair. Findings: LPA had previously spoken to staff regarding the elevator. Based on observation and interviews with staff and residents, elevator two has been out of service since November. Despite efforts made by management to get the elevator repaired, it remains nonoperational, therefore the allegation above is SUBSTANTIATED. Continued on LIC9099-C Substantiated Continued form LIC-9099 The preponderance of evidence is met, therefore, the allegation is substantiated. Deficiency is cited from Title 22 California Code of Regulations and listed on 809-D. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result civil penalty. Deficiency plan and proof of correction were discussed with BOM. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Apr 22, 2025 · control 15-AS-20250325154908

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Apr 29, 2025

87303 Maintenance and Operation (a) The facility shall be ...in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. Based on observation and records, Elevator two has been inopeerational since November.the state’s words, verbatim · CDSS document, Apr 22, 2025

Plan of correction: Executive Director now has a clear date of May 5th to have the elevator repaired. Deficiency cleared during visit.

Allegation investigated: Facility does not employ a qualified food service consultant Disaster drills are not being conducted as required

On 04/22/2025 at 11:10 AM, Licensing Program Analyst (LPA) D. Doidge unannounced to conduct a 10 day initial complaint investigation for the allegation above. Upon arrival, LPA met with Fouzia Yaagoub, Business Office Manager to open a complaint. During the course of the investigation, LPA conducted interviews with staff, and received and reviewed the Disaster Drill Log. Allegation: Facility does not employ a qualified food service consultant. Findings: Based on interviews with staff, LPA confirmed the facility does have a full-time employee qualified by formal training for food planning, preparation and service, as well as a dietician to consult in meal preparations. Therefore this allegation is UNSUBSTANTIATED. Continued on LIC9099-C Unsubstantiated Continued from LIC-9099 Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation above does not meet Regulation Requirements and is unsubstantiated. Allegation: Disaster drills are not being conducted as required. Findings: Based on record review, and staff interviews, LPA confirmed disaster drills are held monthly and logged appropriately. Therefore this allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation above does not meet Regulation Requirements and is unsubstantiated. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 22, 2025 · control 15-AS-20250417130751

Allegation investigated: Facility does not have sufficient staff to meet residents needs in the provision of food services.

On 04/22/2025 at 11:10 AM, Licensing Program Analyst (LPA) D. Doidge unannounced to conduct a 10 day initial complaint investigation for the allegation above. Upon arrival, LPA met with Fouzia Yaagoub, Business Office Manager to open a complaint. During the course of the investigation, LPA conducted interviews with multiple staff, and residents. LPA also obtained, reviewed, and received copies of the LIC500, food service staff shift schedule, Physician's Reports (602) and Apprasial Needs and Services (ANS) for a sample of residents. . Allegation: Facility does not have sufficient staff to meet residents needs in the provision of food services. Findings: LPA observed that there is sufficient staff for food service, and that no resident requires assistance with feeding. Continued on LIC9099-C Unsubstantiated Continued from LIC9099 Record review, and staff interviews confirmed no resident requires assistance with feeding, nor does any resident have a doctor ordered meal time. Therefore the above allegation is Un-Substantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations above do not meet Regulation Requirements are un-substantiated. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 22, 2025 · control 15-AS-20250418133940

Type of visit: Office

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

Allegation investigated: Staff did not ensure the facility elevator is properly operating

On 03/11/2025 at 9:45 AM, Licensing Program Analyst (LPA) D. Doidge arrived unannounced to conduct a 10 day initial complaint investigation for the allegation above. Upon arrival, LPA met with Fouzia Yaagoub, Business Office Manager, and explained the reason for the visit. During the course of the investigation, LPA conducted an interview with Fouzia, interviewed the head of maintainance, and spoke with/observed the elevator repair technition from Metro repairing elevator. LPA also interviewed residents. Allegation: Facility elevator is in disrepair. Investigation Finding: Un-Substantiated Continued on LIC9099-C Unsubstantiated Continued from LIC9099 LPA interviewed two (2) residents (R1, R2) regarding the allegation. Both residents spoke about how elevator 1 had been closing on residents. Although the elevator was closing on residents, no injuries were reported by either resident. LPA also interviewed one (1) Staff (S1) in this matter. S1 reported to LPA that Metro Elevator is Lake Park's elevator repair company. S1 had placed a service call to Metro Elevator the day before due to concerns brought by residents. The Metro Elevator technician was on site repairing the elevator at time of interview with S1. LPA was able to observe the repair technician repair the sensor in the elevator and rode the elevator a few times to ensure it was functioning correctly. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation the facility’s elevator is in disrepair does not meet Regulation Requirements is un-substantiated. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 11, 2025 · control 15-AS-20250307141755

Allegation investigated: Facility elevator is in disrepair.

On 02/21/2025 at 1:20 PM, Licensing Program Analyst (LPA) D. Doidge unannounced to conduct a 10 day initial complaint investigation for the allegation above. Upon arrival, LPA met with Executive Director (ED), Kirsten Korfhage, and explained the reason for the visit. During the course of the investigation, LPA conducted an interview with ED, reviewed and received copies of email coorrespondence with the elevator manufacturer for the elevator. LPA also interviewed residents. Allegation: Facility elevator is in disrepair. Investigation Finding: Un-Substantiated It was reported to the Department that the facility's elevator is in disrepair. Upon observeation of rhe elevator, interviews and review of service/maitance logs, LPA determined elevator is in process of being repaired. Continued on LIC9099 Unsubstantiated Continued from LIC9099 Elevator 2 stopped working early January. ED informed Otis, the elevator manufacture, and put in a service request. On February 3rd, Otis technicians repaired by installing the part and informed ED they would need to come back to put the elevator back in operation. The facility is waiting for Otis to come back out and finish the job. In the meantime, ED has been in contact with three (3) other repair companies to either repair or replace the current elevators. ED has documentation showing there is a not only a plan to repair the elevators, but a reasonable timeline for the repair has been established. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation the facility’s elevator is in disrepair does not meet Regulation Requirements is un-substantiated. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Feb 21, 2025 · control 15-AS-20250219150136

Allegation investigated: Staff mismanaged resident's medication.

On 01/23/2025 at 11:57 AM, Licensing Program Analysts (LPAs) D. Doidge and C. Fowler arrived unannounced to deliver complaint findings for the allegation above. Upon arrival, LPAs met with Executive Director, Kirsten Korfhage, and explained the reason for the visit. During the course of the investigation, the Department conducted interviews with a witness, current and former, staff. The Department obtained and reviewed the facility & staff roster, MAR, Medication Count Sheet, Physician’s Report and Medication Staff Communication Log. Allegation: Staff mismanaged resident's medication. Investigation Finding: Un-Substantiated Continued on 90999-C Unsubstantiated Continued from 9099 It was reported to the Department that the facility staff mismanaged resident’s medication. The department conducted interviews and reviewed R1’s MAR, medication count sheet, physician report, care plan, and medication staff communication log which revealed that R1 was provided PRN medication as (needed) prescribed. Medication was removed from the facility before LPA could verify count. Therefore, this allegation is Un-Substantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation Staff mismanaged resident's medication is un-substantiated.the state’s words, verbatim · CDSS document, Jan 23, 2025 · control 15-AS-20240216172359

Allegation investigated: The facility’s Disaster Plan does not meet Regulation Requirements

On 01/23/2025 at 1:28 PM, Licensing Program Analysts (LPAs) D. Doidge and C. Fowler, arrived unannounced to conduct a 10 day initial complaint investigation for the allegation above. Upon arrival, LPAs met with Executive Director, Kirsten Korfhage, and explained the reason for the visit. During the course of the investigation, LPAs conducted an interview with staff, reviewed and received a copy of the staff roster, and the Disaster Plan. Allegation: The facility’s Disaster Plan does not meet Regulation Requirements. Investigation Finding: Un-Substantiated It was reported to the Department that the facility’s Disaster Plan is out of compliance. The RO received further information that the Evacuation component of the Disaster Plan has an expired date. Upon interview and review of the Disaster Plan, LPAs observed the plan to be current. Continued on LIC9099 Unsubstantiated Continued from LIC9099 Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation facility’s Disaster Plan does not meet Regulation Requirements is un-substantiated. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jan 23, 2025 · control 15-AS-20250117120802

Allegation investigated: Staff did not provide resident’s authorized representative with records Staff did not provide resident with privacy

On 1/9/2025 at 1:30pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to deliver complaint findings for the allegations above. LPA met with Kirsten Korfhage, Executive Director and explained the reason for the visit. During the course of the investigation the Department conducted interviews with staff, witnesses, resident, obtained and reviewed records. Staff did not provide resident’s authorized representative with records. Based on interview with W1 the facility did not provide R1’s responsible party with requested documentation in R1’s file in a timely manner. W2 stated the documentation was first requested late 2023 to early 2024. LPA reviewed an email Continued on LIC9099C. Substantiated Continued from LIC9099. dated August 9, 2023, that requested documentation from the facility for R1. There was another email on April 23, 2024, that involved the Ombudsman regarding documentation for R1’s responsible party, lastly LPA reviewed an email dated April 25, 2024, that indicated R1’s responsible party received documentation. Staff did not provide resident with privacy. Based on initial interview W1 stated the staff are disturbing and not providing the resident with privacy by constantly coming into the resident’s room. W2 stated during interview staff would barge in R1's room without knocking. Review of charting records from October 2023 to April 2024 indicated how many times staff come in R1’s room per day and what was done or said. LPA observed that on some days staff charted 10 different times staff would go to R1’s room. S6, S7, and S8 stated during interview that staff was instructed by S4 to go to R1’s room to do checks. S7 and S6 stated this is not done to all residents. Same staff stated R1 does not get as many checks now just a few reminders. Based on LPA observations, interviews which were conducted, and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted. A copy of the appeal rights and this report provided. Continued from LIC9099. only staff person that was aware of this type of charting being done to another resident. W2 stated there were two (2) ex-employees told by S4 to get the level of care points up, which would increase the monthly service fee. Staff did not provide a comfortable environment for resident. Based on interview with W2 the facility was not welcoming and was a hostile environment. W2 recalled R1 being put in an elevator to go to the lobby and got lost in the basement. W2 felt this action was done intentionally. Based on review of preplacement appraisal dated 5/27/2023, R1 would not need any assistance moving around facility once fully acclimated to the new environment. LPAs spoke with two (2) residents during visit. Both R1 and R2 did not have any complaints about the facility or staff. LPAs observed both rooms were clean, and residents had their possessions. Staff did not assist resident with hygiene needs. During interview with witnesses both stated R1 did not want assistance with hygiene. W1 stated this allegation should not have been made and maybe there was a misunderstanding when reporting. W2 stated that R1 needed a reminder or help possibly once a day with toileting. Staff did not assist resident with laundry. During interview with witnesses both stated R1 did not want assistance with laundry. W1 stated this allegation should not have been made and maybe there was a misunderstanding when reporting. W2 stated the responsible party takes care of R1’s laundry. Continued on LIC9099C. Continued from LIC9099C. Based upon the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and a copy of report was given.the state’s words, verbatim · CDSS document, Jan 9, 2025 · control 15-AS-20240426144046

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(19) · Plan of correction due date: Jan 24, 2025

(a) In addition to the rights listed in Section 87468.1... the elderly shall have all of the following personal rights: (19) To have prompt access to review all of their records and to purchase photocopies of their records. Photocopied records shall be provided within two (2) business days... This requirement was not met as evidence. Based on observation and interview the Licensee did not comply with the section cited above in providing prompt access to resident's responsible party, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 9, 2025

Plan of correction: Executive Director agreed to have an in-service training on personal rights for all employees and submit sign-in sheet to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(1) · Plan of correction due date: Jan 24, 2025

(a) In addition to the rights listed in Section 87468.1... (1) To have a reasonable level of personal privacy in accommodations... personal care... This requirement was not met as evidence by: Based on interviews and record review the Licensee did not comply with the section cited above in giving resident peronal privacy which poses a potential health and safety risk to person in care.the state’s words, verbatim · CDSS document, Jan 9, 2025

Plan of correction: Executive Director agreed to have an in-service training on personal rights for all employees and submit sign-in sheet to CCLD by POC date.

Allegation investigated: Facility is in financial distress.

On 12/12/2024 at 10:45 AM, Licensing Program Analysts (LPAs) L. Alexander and D. Doidge conducted a subsequent visit and met with Executive Director, Kirsten Korfhage to deliver findings of above allegation. LPA explained the purpose of the visit with Executive Director. During the investigation, the LPA obtained the following documents from the facility – copies of utility billing statements. Allegation: Facility is in financial distress. Finding: Substantiated During the investigation, the LPA conducted interviews of facility staff (S), residents (R) and witnesses (W). On 02/21/2024 and 03/13/2024 LPA obtained copies of utility bills and past due notices for PG&E and Waste Management and observed that the accounts were in arrears. LIC9099-C Continued... Substantiated LIC9099-C (Page 2) On 12/11/2024 LPA interviewed S4. S4 stated that per the Maintenance Director (MD) has confirmed that there was some plumbing work upgrades that were completed in the community regarding the ball valves in 2023. The work was planned with notices be distributed to all of the residents notifying them of the water shut for a period of time on the particular day. The MD explained that they did the A wing one day, drained all of the water, completed the work and turned the water back on. The next day same notices went out to the residents in the B wing and worked commenced the same as the day before. The MD said the work went smoothly with no complaints. S4 further stated that this work was preemptive so that if there was a need to shut off water during an emergency leak, the ball valves would be easier to close. The building had plug valves that were identified as old and needing replacement. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided. LIC9099-C (Page 2) On 02/21/2024 LPA interviewed S2. S2 stated that the facility had received 7-Day Notices from Pacific Gas & Electric Company (PG&E) and past due notices and Final Demand Notices from Waste Management. On 02/23/2024 LPA interviewed W1. W1 stated that they were contacted by Lake Park Senior Living in August 2023 for a sewer lateral repair. W1 stated that they presented a proposal for the project and was hired by Lake Park Senior Living to complete a two (2) phase project. W1 stated that they completed the first phase of replacing five (5) laterals which was invoiced for $42,800.00. W1 stated that the second phase proposal would be “pretty involved” and that they gave an estimated total of $179,410.00. W1 stated that they did not receive payment of $42,800 for the first phase and there was no further communication from management whether to proceed with the proposed second phase of the project. On 02/27/2024 LPA interviewed S1. S1 stated that another contract plumber was hired to replace twenty-seven (27) ball valves. S1 stated that the contractor invoiced on 09/22/2023 for $8,514.99 and that payments have not been paid. On 04/09/2024 LPA interviewed S1. S1 stated that two (2) of the residents (R1 and R2) had one-on-one care attendants in which were arranged by previous administration. S1 stated that the parent company, Pacifica, said that they did not approve the service and were not going to pay for caregiving services. S1 stated that they received a collection notice for non-payment from one of the resident’s caregiver agencies. S1 stated that the pest service, satellite television service was also disconnected for non-payments. LIC9099-C Continued... LIC9099-C (Page 3) Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Dec 12, 2024 · control 15-AS-20240220153014

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87213 · Plan of correction due date: Jan 17, 2025

The licensee shall have a financial plan that … assures sufficient resources to meet operating costs for care of residents…” Based on investigation, licensee did not comply with the section cited above by receiving several past due notices for PG&E (dates 11/29/23 thru 01/30/24), Waste Management (dates 02/14/23 thru 01/10/24; and per W1, contractor has not been paid for work performed.the state’s words, verbatim · CDSS document, Dec 12, 2024

Plan of correction: Administrator agreed to provide evidence that payments for PG&E, WM, pest service, plumber and caregiver services are paid and accounts are current and wil submit proof to CCLD by POC due date.

Allegation investigated: Facility not complying with approved plan of operation

On 12/10/2024 at 2:45 PM, Licensing Program Analyst (LPA), D. Doidge accompained by Licensing Program Manager (LPM) J. Fong, conducted an unannounced continuing complaint visit, meeting with Executive Director, Kirsten Korfhage, and explained the nature of the visit. Allegation: Facility not complying with approved plan of operation Finding: Substantiated At complaint filing, the Department was informed that the electronic admission agreement that Lake Park is utilizing was incorrect and had conflicting terms and language; whereby language pertaining to independent individuals aged 55 and older was comingled with language pertaining to licensed RCFE residents. Continued on LIC 9099-C Substantiated Continued from LIC9099 Per previous complaint filed on 4/2/24, Control Number 15-AS-20240402175048, with the allegation that the facility changed the plan of operation without CCLD approval, a copy of an admission agreement was obtained which did show that there was language pertaining to independent, general renters, aged 55 and older that was mixed with licensed RCFE language. Therefore, the allegation was previously investigated and substantiated on 7/25/24. The allegation for this complaint, Control Number 15-AS-20240701153826, is Substantiated, however no deficiencies are being issued on today’s date due to the previous Substantiation and Deficiencies cited on 7/25/24. Exit Interview conducted, and a copy of this report and appeal rights were provided. Continued from LIC9099 Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation Staff mismanaged resident's medication is un-substantiated. Exit interview conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Dec 10, 2024 · control 15-AS-20240701153826

Allegation investigated: Facility staff are inadequately trained Facility has insufficient staffing

On 12/04/2024 at 2:00 PM, Licensing Program Analysts (LPAs) Carol Fowler and David Doidge arrived unannounced to deliver complaint findings for the allegation above. Upon arrival, LPA met with Executive Director, Kirsten Korfhage and explained to her the reason for the visit. During the course of the investigation, the Department conducted interviews with residents, staff, and witnesses. The Department obtained and reviewed the facility & staff roster, staff schedule and staff trainings. LPAs also reviewed a sample of resident’s re-appraisal and Physicians Reports. Allegation: Facility staff are inadequately trained Investigation Finding: Substantiated It was reported to the Department that the facility staff has insufficient training hours. continue on LIC9099C Substantiated continue from LIC 9099 The department conducted interviews and reviewed training documents which reveal that several staff are insufficient in required training's which provides knowledge and skills needed to provide the care and needs of the residents. Therefore, this allegation is Substantiated. Allegation: Facility has insufficient staffing Investigation Finding: Substantiated It was reported to the Department that the facility is short staffed during NOC shift. Review of staff schedules and interview with staff and residents revealed that there is 1 caregiver and 1 medication technician on staff during NOC shift. Interviews with residents also revealed that there are residents which require two persons transfer which would leave no staff available if staff had to attend to one of the other residents. Therefore, this allegation is Substantiated. Based on the Department’s investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D. Exit interview conducted. A copy of this report and appeal rights provided. Continue from LIC 9099 A The Department reviewed samples of resident’s files (7 out of 21 sampled), conducted interviews with staff and residents which revealed 1 resident out of the 7 with an expired re-appraisal. Therefore, this allegation is unsubstantiated. Allegation: Facility does not have a required Dietician Investigation Finding: unsubstantiated It was reported to the Department that the facility does not have a dietician as required for RCFE’s with a capacity of 50 or more residents. The Department conducted interviews and reviewed documents which revealed that the facility has a dietician on staff that signs off all menus and is available to residents if requested. Therefore, this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegations that the facility has not performed required annual re-appraisals and facility does not have a required dietician. Exit interview conducted. A copy of this report provided.the state’s words, verbatim · CDSS document, Dec 4, 2024 · control 15-AS-20240811203347

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(d) · Plan of correction due date: Jan 6, 2025

(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or rel...ing, as appropriate for the job assigned and as evidenced by safe and effective job performance: This requirement is not met as evidenced by: Based on interviews and file reviews, the licensee did not comply with the section cited above in not ensuring staff training's are current which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Dec 4, 2024

Plan of correction: Administrator will ensure all AL staff training's are current and up to date and submit proof to CCL by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Jan 6, 2025

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs....Additional staff shall be employed as necessary to perform office work,...buildings..... and grounds...... Based on interviews and record review the licensee did not comply with the section above for not having sufficient staff to meet residents' needs such as assistance with 2 person transfers, diapering needs during NOC shift, which posed potential health and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Dec 4, 2024

Plan of correction: Executive Director (ED) to ensure sufficient staffing. ED to have the following submitted by 1/6/2025: 1. LIC500 Personnel Report 2. Staff schedules for all shifts in the assisted living unit.

Type of visit: Required - 1 Year

On 12/04/2024 at 02:00 PM, Licensing Program Analysts (LPAs) D. Doidge and C. Fowler arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with, Executive Director, Kirsten Korfhage and explained the purpose of the visit. LPAs toured the facility including but not limit to, bedrooms, bathrooms, multiple activity rooms, kitchen, and common area. LPAs observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 72 degrees Fahrenheit. The hot water temperature in a common bathroom was measured at 112.2 degrees Fahrenheit. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps are locked and inaccessible to residents in care. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 08/12/2024. Emergency disaster drill was last conducted on 11/26/2024. First aid kit was observed to be complete. LPAs reviewed five (5) resident records and five (5) staff records, all were complete. No deficiencies observed or cited during this visit. . Exit interview conducted and a copy of this report providedthe state’s words, verbatim · CDSS document, Dec 4, 2024

Allegation investigated: Staff interfering with designation of responsible person for resident.

On 11/22/2024 at 9:00 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to deliver findings for the above allegation. LPA met with Executive Director (ED), Kirsten Korfhage and explained the purpose of the visit. LPA conducted a complaint investigation in relation to the allegation of "staff interfering with the designation of a responsible person for the resident." During the course of the investigation, LPA reviewed various records, conducted interviews, and obtained additional documents to fully understand the situation and to determine whether the allegation was substantiated. Report continues on LIC 9099-C Unsubstantiated continued from LIC-9099 On 5/03/2024, LPA conducted an initial visit where they conducted interviews and record review. LPA reviewed R1’s Admissions Agreement, which indicated that R1 was admitted to the facility as an independent resident on 1/10/2018. LPA also reviewed physician reports, including a previous report from 12/6/2017 that stated R1 was fully independent, as well as a report dated 3/27/2024, which showed R1 had been diagnosed with dementia and experienced confusion and memory loss. During the investigation, LPA observed that R1 was initially in charge of their own affairs and had an emergency contact listed. However, through interview with previous ED and review of email correspondences LPA found that as concerns regarding R1’s cognitive decline arose, the previous ED contacted the emergency contact (W2) and R1’s Financial Advisor (W3) for guidance on 3/4/2024. The previous ED explained that, based on their observations of R1’s deteriorating condition, they reached out to W3 who is R1's financial advisor to express concerns about R1’s cognitive abilities and the potential risks to R1’s well-being. Previous ED was advised to contact R1’s attorney (W4) for POA information but previous ED never was able to reach W4 before they found out about the new POA. In the time while previous ED was trying to get in contact with W4, W2 took R1 to get a new physicians report. The previous ED stated that they followed the chain of contact, as outlined in R1's original documents, which specified the first emergency contact in case of concern. LPA reviewed and confirmed that based on R1’s emergency contact sheet the previous ED contacted the appropriate person. According to the original Emergency contact sheet W2 was designated as first person to be contacted for R1. The updated Emergency Contact sheet from 3/13/2024 still had W2 listed as the first point of contact for R1. Report continues on LIC-9099C continued from LIC-9099C The previous ED explained that after making the necessary contacts, including with R1's emergency contact W2 and financial advisor W3, an unrelated individual, referred to as W1, became involved and was designated as R1's medical POA on 3/8/2024. The previous ED expressed concern that this individual, who was not previously known to the facility or listed in R1’s documentation, could be potentially taking advantage of R1. The previous ED also contacted W2 3/14/2024 R1's emergency contact to discuss the situation further. Subsequently, R1 was taken for a medical evaluation on 3/27/2024, where it was confirmed that R1 had dementia and was unable to manage medications, leave unassisted, or access grooming items. LPA reviewed the visitor log for 3/8/2024, which showed that a notary signed in to visit R1, the same day W1 was listed the new POA, although there was no sign in for W1. The previous ED stated that their concern was that, due to the involvement of an individual who was not previously known to the facility and who was unrelated to R1, there was a potential risk of R1 being exploited. However, the previous ED adhered to the appropriate procedure by contacting R1’s emergency contact, as indicated in R1's original documentation, and did not interfere with the POA designation. Although there were concerns about R1’s cognitive decline and the involvement of an unknown individual, there is insufficient evidence to support the allegation that staff interfered with the designation of a responsible person for the resident. The previous ED followed the appropriate steps, as outlined by the documents approved by R1, and contacted the correct parties in response to the concerns raised. Therefore, the allegation of “staff interfering with the designation of a responsible person for the resident” is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Nov 22, 2024 · control 15-AS-20240503094454

Type of visit: Case Management - Other

On 11/22/2024 at 9:50AM Licensing Program Analyst (LPA) A. Gomez conducted an unannounced Case Management visit. LPA met with Executive Director, Kirsten Korfhage and explained the purpose of the visit. While LPA was conducting a complaint investigation, #15-AS-20240503094454, on 5/03/2024, LPA observed during visit that the facility was not requiring visitors to sign in and allowing them to go up to residents apartments without signing in exposing them to their personal rights being violated by unknown persons. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 22, 2024

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.269(a) · Plan of correction due date: Nov 22, 2024

(a) Residents of residential care facilities for the elderly shall have all of the following rights: This requirement was not met as evidenced by: Based on observation and interviews from investigation the facility was not monitoring individuals coming into the facility or requiring them to sign in which posed a potential safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 22, 2024

Plan of correction: LPA observed that facility has implemented a mandatory sign in sheet where you can not enter before signing in POC cleared

Allegation investigated: Facility is overcharging resident.

*THIS IS AN AMENDMENT OF REPORT DATED 11/08/2024* At 10:55 am, Licensing Program Analysts (LPAs) A. Delmundo and D. Doidge arrived unannounced to investigate the above allegation. LPAs met with Business Office Manager (BOM) Fouzia Yaagoub and informed the reason for visit. It was alleged that resident (R1) was charged $250.00 late payment charge and $50.00 for no sufficient fund (NSF). The $250.00 was reversed but not the $50.00. LPAs interviewed BOM who confirmed the $250.00 was reversed but not the $50.00. BOM stated she communicated with their corporate office and was told that they are not reversing the $50.00 because the facility was charged by the bank for NSF. .....continued on 9099C Unsubstantiated LPAs interviewed R1 who stated R1 has sufficient fund in R1's account and there's nothing showing R1 was charged by the bank for NSF. LPAs reviewed R1's bank statements which showed R1 issued check for 2 months rent for June 2024 and July 2024 and had an automatic payment deducted from R1's account on July 8, 2024. Lake Park returned the one month payment on July 3, 2024 and charged R1 for $50.00 for NSF. Based on interviews and records review, the preponderance of evidence is met, therefore, the allegation is unsubstantiated. An unsubstantiated findings mean that although the allegation may have happened or is valid there is not a preponderance of evidence that the violation occurred. No Deficiencies cited. Exit interview conducted. Copy of this report provided.the state’s words, verbatim · CDSS document, Nov 8, 2024 · control 15-AS-20241030085123

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Nov 22, 2024

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, .....residents in privately operated residential care facilities for the elderly shall have all of the following personal rights.... No dificiency citedthe state’s words, verbatim · CDSS document, Nov 8, 2024

Plan of correction: ***

Type of visit: Case Management - Other

On 10/09/2024 at 4:00 PM Licensing Program Analysts (LPAs) L. Alexander and D. Doidge arrived unannounced to conduct a Case Management visit. LPAs met with Executive Director (ED), Kirsten Korfhage. While LPA L. Alexander and D. Doidge was conducting a complaint investigation (15-AS-20240811203347). LPA were informed back on 09/17/2024 that Northstar (management and Pacifica (ownership) did not have a surety bond. LPAs interviewed ED and asked if the facility holds the resident's cash. ED stated no and that residents may have a fiduciary or banker that manages their money. No deficiencies issued during the visit. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 9, 2024

Allegation investigated: Staff are not ensuring a healthful environment for residents in care. Licensee does not provide adequate food services for residents.

On 09/09/2024 at 2:15 PM, Licensing Program Analyst (LPA) James Sampair arrived at the facility unannounced to complete the investigation of the allegations above. The LPA stated the purpose of the visit to Executive Director (ED) Kirsten Korfhage. The complaint alleges that staff are not ensuring a healthful environment for residents in care. The LPA interviewed the Reporting Party (RP) who stated the high level of sound in common areas. Noise and brain health are outside the jurisdiction of the Department. The complaint alleges that the Licensee does not provide adequate food services for residents. The LPA interviewed the RP and residents who stated that the problem has been resolved and the food is now adequate. Continued on LIC 9099-C... Unsubstantiated ...Continued from LIC 9099 Although the allegations may have happened, or are valid, there is not a preponderance of evidence to prove them; therefore, the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 9, 2024 · control 15-AS-20240212093033

Allegation investigated: Staff did not provide safe transportation for resident

On this day, 8/1/2024, at 8:30 a.m., Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to investigate the above allegation. LPA met with Front Desk, Brooklyn Manuel. LPA asked to speak with Executive Director but were told that she will not be in until the following week. LPA asked to speak to the next point person Business Office Manager (BOM), who was not available front desk left a message. LPA was greeted by the activity director, Kenia Tobete. LPA explained the purpose of the visit after getting verbal apporval from pointed person for Kenia to sign the report. It was alleged that Staff did not provide safe transportation for resident. Report continued on LIC 9099C… Unsubstantiated During investigation LPA obtained copies of resident roster, transportation planner in the month of May till present, and confirmation receipt from private company that facility call to arranged transportation to residents that are wheelchair bond. LPA interviewed residents that identify by activity director who are wheelchair bond. 2 out of 3 residents stated that facility staff do not transport them in the facility minivan nor the 14-passenger van, because there is no way our wheelchair can get in. LPA attempted to interview R1 but R1 didn’t want to be interview. LPA interviews staffs. 5 out of 5 staff stated that they have not transport any residents or have seen any staff that transport residents that are wheelchair bond on the mini-van nor the 14 passenger’s van. 5 out of 5 stated that residents that are wheelchair bond cannot get on to the mini-van or the 14 passenger’s van, because it’s impossible to get the wheelchair in for both van. S2 stated that S2 arranged all the transportation during the time that the main bus that transport wheelchair bond break down. S2 arranged transportation from residents who is wheelchair bond from their sister facility or the private company that specialized in transferring wheelchair bond. Based on information gathered, the allegation is closed as unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Aug 1, 2024 · control 15-AS-20240730151503

Allegation investigated: The facility has changed the plan of operation without CCLD approval.

On 07/25/2024 at 9:50 AM, Licensing Program Analyst (LPA) L. Alexander conducted a subsequent visit and met with Executive Director, Kirsten Korfhage to deliver findings of above allegation. LPA explained the purpose of the visit with Executive Director. Allegation: The facility has changed the Plan of Operation without Community Care Licensing Division (CCLD) approval. Finding: Substantiated LIC9099-C Continued... Substantiated On 3/28/24, the agency was informed by senior staff of the facility that the plan of operation had been changed and that it would be leasing units to independent renters who are age 55 and above, and to Section 8 recipients. During the investigation, the Department conducted interviews with staff, clients, witnesses, and reviewed records. LPA interviewed the Reporting Party (RP) who again stated that the Licensee instructed staff that the facility will start leasing apartments in the facility to 55+ independent residential renters, as well as to Section 8 recipients; and that these renters would not be subject to RCFE requirements to obtain current Physician Reports, Tuberculosis testing nor Background Clearance checks as residents outside of RCFE services. The RP further stated that these units will be leased on floors with existing residents who were admitted under Residential Care for Elderly (RCFE) and/or Continuing Care Retirement Community (CCRC) contracts. LPA reviewed the Northstar Senior Living, Inc. Assisted Living & Memory Care Program Outline (Plan of Operation) that was submitted to CCLD as part of their licensing application. The Department observed that there is no language or provision indicating that the Plan of Operation would, or possibly at a future date, the Licensee would consider operating with units for 55+ independent residents, nor Section 8 recipients. On 04/08/2024 LPA reviewed a written statement by W1, indicating that W1 had become aware of plans for the facility to begin leasing units to 55+ independent individuals; and that these persons will have access to common areas and the fitness center; and that these persons would not be subject to having a Physician’s Report nor a negative Tuberculosis test prior to moving into the facility. Per the LPAs review of the Licensee’s Plan of Operation, it affirms that the necessary residency forms include a Physician’s Report and Tuberculosis test, which the Executive Director would obtain from all prospective residents. LIC9099-C (Page 2) On 04/09/2024 LPA interviewed S4 who stated that the direction to change the Plan of Operation came from the owner and that facility staff do not communicate directly with the owner, but rather with other executive management. S4 further stated that S2 was interviewed and selected directly by the Licensee’s executive management staff to manage the leasing of units to 55+ independent persons; and that marketing for 55+ has been published on two housing rental websites. On 4/9/24, LPA interviewed S2 who stated having begun working at the site approximately 3 weeks prior. S2 stated that the 55+ rentals would be on the 2nd and 6th floors – which the Department observes to be areas licensed by CCLD. On 4/25/24, LPA obtained and reviewed the document, “Proposed Sale of the Assets of California-Nevada Methodist Homes,” generated between the State of California Department of Justice and the current Licensee, dated January 7, 2020; and observed that it states, “All entities listed in Condition I shall fulfill the terms of these agreements (and)… shall notify the Attorney General in writing of any proposed modification or rescission on any terms of these agreements.” No evidence was found that showed that the Licensee communicated with the Attorney General prior to changing their Plan of Operation. On 06/27/2024, LPA obtained and reviewed a copy of the current admission agreement, "Residence and Services Agreement," and observed that it combines general renter language with standard RCFE language. On 7/15/24, LPA found that the facility’s website is advertising as featuring a “55+ independent living” component. LIC9099-C (Page 3) Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, and the Department has determined that a significant change to the plan of operation affecting the services of residents has been enacted without the approval of the Agency. Therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Failure to correct deficiencies by POC due date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided. LIC9099-C (Page 4)the state’s words, verbatim · CDSS document, Jul 25, 2024 · control 15-AS-20240402175048

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87208 · Plan of correction due date: Aug 15, 2024

“…Any significant changes in the plan of operation…shall be submitted to the licensing agency for approval. This requirement is not met as evidenced by: Based on observations, interviews and record review, the licensee did not comply with the section cited above in by changing the plan of operation without CCLD approval which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 25, 2024

Plan of correction: By POC date, the facility will submit to CCLD for review a new, detailed plan of operation describing the changes that the Licensee wishes to implement.

Allegation investigated: Licensee did not adhere to the terms and condition of Admission Agreement.

On 07/25/2024 at 9:50 AM, Licensing Program Analyst (LPA) L. Alexander conducted a subsequent visit and met with Executive Director, Kirsten Korfhage to deliver findings of above allegation. LPA explained the purpose of the visit with Executive Director. During investigation, the Department obtained the following documents from the facility –residents’ rosters, Residence and Care Agreement California, Lake Park Resident Handbook (P. 29-31) and California-Nevada Methodist Homes (CNMH) "Lake Park" Care and Residence Agreement (Classic Agreement). Allegation: Licensee did not adhere to the terms and condition of Admission Agreement. Investigation Finding: Substantiated LIC9099-C Continued... Substantiated During the investigation, the Department conducted interviews with staff, residents & witnesses; and performed a review of records. On 04/19/2024 LPA interviewed Reporting Party (RP) who stated that Pacifica did not adhere to the Admission Agreement which states that the facility would maintain 24-hour a day Security Service. The RP further stated that facility vans had been vandalized in the parking lot, that there is no security at the front lobby door and no working security cameras on the premises. The Department further found that per the terms of sale, the CCRC contracts generated with residents under the previous owner would be adhered to by the new/current owners. The LPA observed that the agreement generated under the previous licensee provided that the Licensee “maintains a 24-hour emergency call system, a security entrance system, and security personnel.” The LPA further observed in the 2014 Lake Park Resident Handbook it is stated that “A security guard patrols the buildings and grounds on a regular basis…Lake Park’s security system includes secured entrance doors, camera monitoring of building entrances and parking areas, visitor identification, and 24-hour-a-day security guard service.” On 04/23/2024 LPA interviewed S1, who stated that the previous private security company, Allied Security, was providing the security services a year ago. S1 stated that the current "security service" is performed by "in-house employees." S1 stated that the receptionist at the front desk is there for part of the 24hr security and that the overnight "awake caregivers" provide the security at night. S1 further stated that Allied Security had a station with phone numbers & computers; and were responsible for screening all persons before entering the facility, and for contacting the residents when their visitors arrived. S1 stated that there has not been dedicated security guard service due to non-payment of services rendered since the Spring of 2023. On the same day, the LPA interviewed S2, who stated that the security cameras are no longer operational due to non-payment of services – also since the Spring of 2023. LIC9099-C (Page 2) On 4/23/24, the LPA interviewed R1 and R2, who stated that per the contract generated by the previous Licensee, 24-hour a day security service was on site in the outer lobby area and that the only times a guard wasn’t at the station were during rounds. R1 further stated that shortly following the sale, the new owners had untrained persons serving as “security” stationed at reception; and that the outer front door had been “unlocked” and other persons had been able to access the facility due to the lack of security. On same day, LPA interviewed R3 who stated feeling unsafe; and interviewed R4, who also stated that vehicles in the parking lot had been vandalized & burglarized, that the front door had been unsecured, the garage door has not closed properly since September of 2023, and that resident safety is a concern. R4 also stated that before the sale, a security guard was present who would have to allow visitors access into the facility. Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, and the Department has determined that the facility is not adhering to existing CCRC contracts as required by the California Department of Justice per terms of sale to the current licensee – by removing the 24-hour security provided for in the CCRC contracts. Therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Failure to correct deficiencies by POC due date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided. LIC9099-C (Page 3)the state’s words, verbatim · CDSS document, Jul 25, 2024 · control 15-AS-20240416120139

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1793.2(s) · Plan of correction due date: Aug 15, 2024

§1793.2(s) “…the Department, in its discretion, may condition, suspend, or revoke any…certificate of authority issued under this chapter if it finds that the applicant or provider has done any of the following: (s) Failed to fulfill his or her obligations under continuing care contracts.” This requirement is not met as evidenced by: Based on observations, interviews and record reviews, the licensee did not comply with the section cited above by not providing adequate 24-hour security as specified in existing CCRC contracts – with adherence to existing CCRC contracts being a condition of terms of sale by the California Department of Justice, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 25, 2024

Plan of correction: By POC date, the facility will hire a dedicated 24-hour security service.

Allegation investigated: Staff did not get the proper permits for renovation in the facility

On this day, 06/21/2024, at 2:00 p.m., Licensing Program Analyst (LPA) L. Alexander arrived unannounced to investigate the above allegation. LPA met with Wellness Nurse, Tsering Palmo, and informed the reason for visit. Executive Director, Kirsten Korfhage, arrived shortly later. Allegation: Staff did not get the proper permits for renovation in the facility Substantiated On 06/21/2024, LPA tour the facility kitchen with S2 and observed new commercial kitchen equipment and gas lines moved. S2 stated that the kitchen equipment was being replaced and that the work of deep cleaning the area and installing the new gas lines should be completed by Saturday 06/22/2024. S1 stated that they were informed by Pacifica that the project was equipment replacement and that no permit is required. LPA spoke with W1 with City of Oakland Inspections and Code Enforcement Services and they informed LPA that a permit it required with the removing and changing of gas lines with equipment replacement. The preponderance of the evidence standard has been met, and the allegation is SUBSTANTIATED. Deficiency is cited under the California Health and Safety Code listed on LIC9099-D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted with ED. Appeal Rights and a copy of this report. Substantiatedthe state’s words, verbatim · CDSS document, Jun 21, 2024 · control 15-AS-20240619101457

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87305(a) · Plan of correction due date: Jul 5, 2024

87305 Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all facilities shall obtain a building permit. This requirement was not met as evidenced by: Based on observation and interviews, the Licensee did not comply with the section cited above by getting a building permit before doing alterations in kitchen, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 21, 2024

Plan of correction: Administrator/Licensee will submit a copy of building permit to CCLD by POC due date.

Type of visit: Case Management - Other

On 06/21/2024 at 3:00 PM Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a Case Management visit. LPA met with Executive Director, Kirsten Korfhage. While LPA L. Alexander was conducting a complaint investigation (15-AS-20240619101457) on 06/21/2024. LPA was informed that the food availability was questionable for the residents back on 05/26/2024. During the complaint visit, LPA observed that there was adequate food available. Therefore the food guest services is adequate for the residents. No deficiencies issued during the visit. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 21, 2024

Allegation investigated: Staff did not adhere to resident's admissions agreement.

On this day, 5/29/2024, at 12:20 p.m., Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegation. LPA met with Executive Director (ED) Annemarie Domizio, and informed the reason for visit. LPA also met with Business Office Manager (BOM) Aryanna Henry. It was alleged that the refrigerator in the unit broke and could not be fixed. The facility tried the older units but also failed and the facility declined to purchase a new one when the contract (Admission Agreement) clearly states that the units will have appliances. During investigation. LPA obtained copies of resident roster and Admission Agreements. From the roster, LPA selected 5 residents for interview. ....continued on 9099C Unsubstantiated Admission Agreement submitted to the Department which was approved upon granting of license was reviewed by LPA. Item C of the Admission Agreement under Basic Services indicated in part “The Community will furnish the Apartment with carpeting and/or floor coverings, blinds, paint and/or wall covering on all interior walls and ceilings, convenience kitchen and/or kitchenette appliances, and heating and air conditioning. The Community shall have the sole and exclusive right to determine and select the type, style, design and color of each and every one of the foregoing items. Unless the Resident notifies the Community in writing of any alleged defect in the Apartment prior to the commencement of the Term, the Resident shall be deemed to have accepted the Apartment in an "as is'' condition.” The Admission Agreement also states under item E. Maintenance “The Community shall provide service and repairs for normal wear and tear to electrical and mechanical equipment provided with the Apartment. The Community will impose a charge to the Resident for the cost of replacement or repair of any such equipment that is caused by the Resident's neglect or willful act. Four (4) out of 5 residents interviewed stated there's refrigerator in their room/unit when they moved-in and didn't have problem with it, The other resident stated the refrigerator was not working when this resident moved-in but the staff replaced it immediately without charge. LPA inspected the refrigerators in the 5 residents' rooms/unit which were observed in operating condition. Based on information gathered, the allegation is closed as unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. ED left the facility and BOM stated she can sign and receive this report. Exit interview conducted, and copy of this report provided.the state’s words, verbatim · CDSS document, May 29, 2024 · control 15-AS-20240521083323

Allegation investigated: Facility has pests.

On 04/15/2024 at approximately 9:45 AM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct an initial 10-day complaint investigation visit regarding the allegation above. LPA met with Executive Director (ED), Annemarie Domizio, and explained the purpose for the visit. During the course of investigation LPA interviewed staff. S1 stated there are pests in the kitchen, but the issue has been addressed. Clark Pests Control company (Clark) came out on 4/9/24 to conduct an assessment on the issue. LPA observed that there are multiple traps are places around the kitchen areas. S1 stated Clark have not been out since January, however as of last week Clark started to come and check on the pests’ issue. S1 have seen a better improvement after Clark came out. According to S1 after Clark did their assessment, they stated that there a process that need to be done, so they recommended that they need to be at the facility weekly to eliminate the ongoing pest’s issue. S1 spoke to ED regrading Clark recommendation, and ED agreed/approved with Clark recommendation. Although the allegations may have happened, or are valid, there is not a preponderance of evidence to prove them; therefore, the allegations are UNSUBSTANTIATED. Exit interview conducted with ED and copy of this report provided via email. Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 15, 2024 · control 15-AS-20240405164105

Type of visit: POC

On 4/11/2024 at 2:00PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a POC (Proof of Correction) visit. LPA met with Executive Director (ED), Annemarie Domizio, and informed the reason for the visit. LPA and ED went over the deficiency, the POC and the current billing and payment status for PG&E and Waste Management accounts. The following deficiencies were cleared by visit: 87755(b) - ED identified PG&E and Waste Management accounts are current and paid up through March 2024. Exit interview conducted. A copy of this report and Letter of Deficiency Citations Cleared provided.the state’s words, verbatim · CDSS document, Apr 11, 2024

Type of visit: Case Management - Other

On 04/09/2024 starting at 1:00 PM, Licensing Program Analyst (LPA) L. Alexander conducted a Case Management while at the facility for another matter. LPA met with Executive Director (ED), Annemarie Domizio, and explained the purpose of visit. During a complaint investigation (#15-AS-20240220153014) on 02/21/2024, LPA interviewed Staff and obtained the following documents: 1. Copy of invoices for non-payment for caregiver services 2. Copy of collection notice for caregiver services dated March 21, 2024 3. Copy of account ledgers for DIRECTV and Clark Pest Control 4. Copy of invoices for non-payment for DIRECTV and Clark Pest Control No citations are being issued on this date. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 9, 2024

Type of visit: Case Management - Other

On 03/28/2024 at 12:30 PM Licensing Program Analyst (LPA) Lori Alexander arrived unannounced to conduct a Case Management visit. LPA met with Executive Director, Annemarie Domizio. Pertaining to complaint 15-AS-2024 0220153014, LPA L. Alexander had on 2/21/24, 2/28/24, 2/29/24, 3/1/24, 3/11/24, 3/12/24, and 3/13/24 requested documents and information related to the payment history for all utility accounts, service vendors, the latest invoices/statements paid and the status of outstanding balances. To date, the facility has not provided an accounting of the services related to gas & electricity; and garbage/recycling/organic/bulky waste collection. Documents obtained: Resident Registry List dated 03/22/24 Copy of Synergy Bill Details from dates 09/28/23 thru 03/28/24 The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Mar 28, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87755(b) · Plan of correction due date: Apr 4, 2024

87755 Inspection Authority of the Licensing Agency (b) The licensee shall ensure that provisions are made for private interviews with any resident or any staff member; and for the examination of all records relating to the operation of the facility. Based on record review, the licensee did not comply with the section cited above by providing requested account documents for utilities, vendors accounts and status of outstanding payments which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 28, 2024

Plan of correction: Administrator agrees to submit a full accounting of all utility bills and vendor accounts that had outstanding balances specifically PG&E and WM accounts to CCLD by POC due date.

Type of visit: Case Management - Other

On 3/28/2024 at 4:00 PM Licensing Program Analyst (LPA) Lori Alexander conducted an unannounced Case Management visit pertaining to information received by the Department indicating that the facility intends to rent units to independent 55+ individuals and persons with Section 8 Vouchers. The Department further received information indicating that the management company was told by the Licensee that those persons would not be subject to need for a Physician’s Report nor a Tuberculosis test. LPA met with Executive Director, Annemarie Domizio, for the purpose of gathering additional information. Documents obtained: Copy Lease Agreement for 55+ Copy Offer to Rent and Application Process Copy Pacifica S.D. Management Single Family Residence Rental Application No citations are being issued on this date. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 28, 2024

Type of visit: Case Management - Health Checks

On 03/28/2024 at 2:30 PM, Licensing Program Analyst (LPA) Lori Alexander conducted an unannounced Health and Safety check to address utilities are running, if there is any garbage build up anywhere on site, whether the facility is clean and how the residents are looking. LPA explained the purpose of the visit with Executive Director, Annemarie Domizio. During health and safety check, LPA observed a total of 3 staff members and 3 residents at facility. LPA toured facility with staff (S1), including but not limited to bedrooms, kitchen, bathroom, and common areas. Residents in care appear to be safe and there are no imminent health and safety concerns on today's date. Documents Obtained: Copy February 2024 Activity Calendar Copy Week 4 of Breakfast, Lunch and Dinner Menu No deficiencies cited during the Health and Safety check. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 28, 2024

Allegation investigated: Staff does not ensure facility is equipped with restroom grab bars. Staff does not ensure facility restrooms have toiletries. Staff does not ensure facility restrooms are kept clean.

On 2/16/2024 at 9:30 AM, Licensing Program Analyst (LPA) J. Sampair arrived at facility unannounced to conduct an initial 10-day complaint investigation visit concerning the allegations above. Upon entry, the LPA informed Business Office Manager (BOM) of the purpose of the visit. The BOM informed the Executive Director (ED) Annemarie Domizio. Allegation: Staff does not ensure facility is equipped with restroom grab bars. The LPA made observations and conducted interviews of staff and residents. Though there are not ADA-compliant grab bars currently in the public restrooms used by facility residents, the ED stated that there have been supply delays during the renovation and that by the end of February 2024 the updates will be complete. Report Continued on LIC9099-C... Unsubstantiated ...Report Continued from LIC9099 Allegation: Staff does not ensure facility restrooms have toiletries. LPA observed that the public restrooms used by facility residents did have toiletries. Allegation: Staff does not ensure facility restrooms are kept clean. LPA observed that the public restrooms used by facility residents did have toiletries. Although the allegations may have happened, or are valid, there is not a preponderance of evidence to prove them; therefore, the allegations are UNSUBSTANTIATED. Exit interview conducted with ED. Appeal Rights and a copy of this report provided via email.the state’s words, verbatim · CDSS document, Feb 16, 2024 · control 15-AS-20240215100833

Allegation investigated: Staff not following resident's care plan. Facility is in disrepair.

On 2/9/2024 at 9:00 AM, Licensing Program Analyst (LPA) J. Sampair arrived at facility unannounced to conduct an initial 10-day complaint investigation visit concerning the allegations above. Upon entry, the LPA informed Business Office Manager (BOM) of the purpose of the visit. The BOM informed the Executive Director (ED) Annemarie Domizio by phone. Allegation: Staff not following resident's care plan. – Unsubstantiated On 2/9/2024, the LPA interviewed Staff S1. S1 stated that there had been no disruption in R3’s showers that are sometimes bed baths due to R3’s frailty. The entries in the shower log showed that they received showers or bed baths on a weekly basis, which was 4 times during the month of January 2024. Report Continued on LIC9099-C... Unsubstantiated ...Report Continued from LIC9099 Allegation: Facility is in disrepair. – Unsubstantiated On 2/9/2024, the LPA interviewed Staff S1 about the amount of time that the shower was not available for residents during the renovation of the handicap accessible shower on the third floor. S1 stated that the time for the renovation was 4 days and that there had been no disruption in care for residents, as was verified by the entries in the shower log. Although the allegations may have happened, or are valid, there is not a preponderance of evidence to prove them; therefore, the allegations are UNSUBSTANTIATED. Exit interview conducted with ED. Appeal Rights and a copy of this report provided via email.the state’s words, verbatim · CDSS document, Feb 9, 2024 · control 15-AS-20240207121356

Allegation investigated: Facility is in disrepair

On 2/9/2024 at 9:00 AM, Licensing Program Analyst (LPA) J. Sampair arrived at facility unannounced to deliver the finding concerning the allegation above. Upon entry, the LPA informed Business Office Manager (BOM) of the purpose of the visit. The BOM informed the Executive Director (ED) Annemarie Domizio by phone. Allegation: Facility is in disrepair. – Substantiated On 2/5/2024, the LPA observed that the security door at the front of the building and the security door into the building from the garage were propped The preponderance of the evidence standard has been met, and the allegation is SUBSTANTIATED. Deficiency is cited under the California Health and Safety Code listed on LIC9099-D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted with ED. Appeal Rights and a copy of this report provided via email. Substantiated ... Report Continued from LIC9099 Allegation: Staff did not provide a safe environment for residents – Unsubstantiated On 2/2/2024 and 2/5/2024, the LPA interviewed Residents R1, R2, R3, and R5 who stated that their safety concerns were related to the lack of security guards (as addressed in the 3/10/2023 complaint that was substantiated on 2/1/2024) and the non-operational security doors at the front of the building and in the basement already cited in this complaint. During the LPA’s tours of the facility on 2/5/2024 and 2/9/2024, there were no other safety violations identified by the LPA. Although the allegations may have happened, or are valid, there is not a preponderance of evidence to prove them; therefore, the allegations are UNSUBSTANTIATED. Exit interview conducted with ED. Appeal Rights and a copy of this report provided via email.the state’s words, verbatim · CDSS document, Feb 9, 2024 · control 15-AS-20240129153841

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Mar 1, 2024

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: Based on observation and interviews, the Licensee had not repaired the front door for over a month and the basement door for more than four months, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 9, 2024

Plan of correction: The Licensee shall repair both the front and the basement doors on or before the due date.

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

On 2/5/2024 at approximately 10:00 AM, Licensing Program Analyst (LPA) J. Sampair conducted an unannounced initial 10-day complaint investigation. Upon entry, the LPA informed Executive Director (ED) Annemarie Domizio of the reason for the visit. During the visit, the LPA discovered that emergency drills were not being conducted and cited the facility for that (refer to 809-D for details). Exit interview conducted with Business Office Manager (BOM) Aryana Henry. A copy of this report provided via email.the state’s words, verbatim · CDSS document, Feb 5, 2024

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.695(c) · Plan of correction due date: Feb 20, 2024

Emergency Plans (c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios ... Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement was not met as evidence by: Based on the lack of proof that quarterly emergency drills are being conducted, and statements from both residents and staff members that they have not been occurring, the licensee has not been complying with the section cited above.the state’s words, verbatim · CDSS document, Feb 5, 2024

Plan of correction: By the due date, the Licensee shall: (1) schedule the quarterly emergency drills for 2024, (2) conduct the first of those emergency drills during each shift, and (3) send proof to LPA that 1 and 2 have been completed.

Allegation investigated: Staff person entered resident's unit by force without authorization

On 2/1/2024 at 1:50PM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to delivered finding for the allegations above. LPA met with Excutive Director, Annwmarie Domizio and explained the purpose of the visit. Allegation: Staff Person entered resident’s unit by force w/out authorization – Unsubstantiated On 3/20/23 LPA KN interviewed R1, who stated he had requested to meet with S2 – and that without warning S2 arrived to the unit with S1. R1 stated he informed S1 that R1 did not need to meet with S1 and verbally would not allow S1 entrance to the apartment, with S1 stating that S1 was the Executive Director and had authorization to enter – and then did so. Report Continued on LIC9099C... Unsubstantiated On 3/20/23 LPA KN interviewed S1 and S2, who denied having forced their way into R1s apartment. S1 stated that R1 had made an appointment to meet in R1s unit. When S1, accompanied by S2 arrived, R1 welcomed both staff persons into the unit. LPA KN spoke to R2, who also resides in the unit, and found that R2 was not present during the event, and had not heard anything pertaining to the allegation. No other potential witnesses were identified. No deficiency cited during visit. Exit interview conducted and a copy of this report provided via email.the state’s words, verbatim · CDSS document, Feb 1, 2024 · control 15-AS-20230319183113

Allegation investigated: Facility illegally evicted resident. Facility hired an aide for resident without obtaining consent.

On 2/1/2024 at 12PM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to delivered finding for the allegations above. LPA met with Executive Director, Annemarie Domizio and explained the purpose of the visit. Allegation: Facility illegally evicted resident – Substantiated On 3/20/23, LPA KN interviewed the RP (Reporting Party) who stated that RP was admitted to the facility under the previous licensee as a CCRC resident without memory care issues. On March 2, 2023, RP was informed that R1 had wanted to leave the building and had to be redirected back to her room; and that R1 would need to be moved to another facility with a memory care unit, or have a 1:1 aide around the clock. LPA reviewed the originating CCRC contract and observed that it stated that residents who develop memory care conditions would be retained by the facility. the current Licensee/facility is to adhere to existing contracts agreed upon with the previous Licensee. Report Continued on LIC9099C... Substantiated LPA obtained a copy of letter to R1, dated 3/12/23, whereby R1 was being evicted as the facility does not accept or retain memory care residents. On 3/20/23, LPA interviewed the Administrator who confirmed that the eviction letter was issued to R1 and that the family needed to hire/pay for an outside 1:1 aide. It was further found that per the terms of the sale of the business, the current Licensee/facility is to adhere to existing contracts agreed upon with the previous Licensee. Deficiency is cited under California code, Health and Safety listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted with Business Office Manager, Aryanna Henry . Appeal Rights and a copy of this report provided via email.the state’s words, verbatim · CDSS document, Feb 1, 2024 · control 15-AS-20230314095133

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1793.21(s) · Plan of correction due date: Feb 16, 2024

1793.219(s). The department, in its discretion, may condition, suspend, or revoke any permit to accept deposits, provisional certificate of authority, or certificate of authority issued under this chapter if it finds that the applicant or provider has done any of the following: (s) Failed to fulfill his or her obligations under continuing care contracts. This requirement was not met as evidence by: Based on observation and record review, the licensee did not comply with the section cited above... LPA reviewed the originating CCRC contract and observed that it stated that residents who develop memory care conditions would be retained by the facility. LPA obtained a copy of letter to R1, dated 3/12/23, whereby R1 was being evicted as the facility does not accept or retain memory care residents. On 3/20/23, LPA interviewed the Administrator who confirmed that the eviction letter was issued to R1 and that the family needed to hire/pay for an outside 1:1 aide. It was further found that per the terms of the sale of the business, the current Licensee/facility is to adhere to existing contracts agreed upon with the previous Licensee.the state’s words, verbatim · CDSS document, Feb 1, 2024

Plan of correction: POC: Provide proof of retriving the eviction letter from R1 to be submitted to CCLD by 2/16/24.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.80 · Plan of correction due date: Feb 16, 2024

ARTICLE 7.5. Resident Participation in Decisionmaking [1569.80- 1569.80.] This requirement was not met as evidence by: Based on observation and record review, the licensee did not comply with the section cited above... On 3/20/2023 LPA KN interviewed the Administrator, who stated that the facility had informed the RP of a need for a 24 hour 1:1 aide. LPA found that the facility did not issue an advance 30-day written notice of a new need and the associated costs – as required.the state’s words, verbatim · CDSS document, Feb 1, 2024

Plan of correction: POC: Pull back the third party staff person and charges; and write addendum to the Plan of Operation describing how they will handle the need for necessary additional staff for a resident.

Allegation investigated: Insufficient Food Service Facility not providing security personnel per admission agreements Facility staff not according residents dignity Facility interfering with residents exercising rights

On 2/1/2024 at 9:30AM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to delivered finding for the allegations above. LPA met with Executive Director, Annemarie Domizio and explained the purpose of the visit. Allegation: Insufficient Food Service – Substantiated On 4/6/23 and 4/7/23, CCRC AGPA Jennifer Walden interviewed S1, S2, S3, and S4; and obtained an email notification from the facility to residents regarding food service changes and the elimination of the salad bar and the buffet – effective 1/14/23, dining committee notes, the Resident Service Agreements generated under the previous Licensee, and Town Hall Meeting notes from 12/29/22 which stated that the Administrator informed the residents that the salad bar and buffet would removed completely. AGPA JW found that the facility had changed and eliminated components of the food service without providing at least 30 days written notice, and that the Licensee Provider had not held a meeting 60 days prior to adjustments in “policies, programs, or services that would materially change the operation or environment of the community as required by the Health & Safety Code and CCRC requirements.” Report Continued on LIC 9099C... Substantiated Allegation: Facility not providing security personnel per admission agreements – Substantiated On 3/20/2023 LPA KN obtained reviewed the CCRC contracts of residents admitted under the previous licensee, which indicated that the facility would provide 24 hour security guard service. LPA found that per the terms of the facility sale, the current licensee was to honor the existing CCRC contracts and Admission Agreements. LPA observed that the agreement generated under the previous Licensee provided that the Licensee “maintains a 24-hour emergency call system, a security entrance system, and security personnel. LPA interviewed R1 through R10 who stated that after the sale, the current Licensee terminated the guard service and assigned monitoring of the front door to staff employed directly by the facility who had other primary responsibilities (front desk staff). On 4/6/23 and 4/7/23, AGPA JW interviewed S1 through S4 and obtained an email communication between the facility and residents – which stated that the services of an outside Security Service were only in place until the Saturday/Sunday positions were filled and that front desk staff and additional personnel would provide security during working hours. R1 through R4 stated that there are times when no staff are near the entrance. LPA interviewed S1 who confirmed that the security service had been terminated. Report Continued on LIC 9099C... Allegation: Facility staff not accorded residents with dignity – Substantiated On 3/20/2023 LPA KN interviewed RP and R1 through R10 who stated that S1 does not treat them with dignity, with RP stating that S1 had yelled at them during council meetings. R1 further stated that the facility informed residents that it was not a Continuing Care Retirement Community, had threatened residents with higher charges and/or eviction if new agreements were not signed, and that the facility would not address their concerns regarding the facility’s CCRC status. R5 reported that S1 has lied to the residents when discussing the terms of the existing CCRC agreements that were to be adhered to, with S1 stating that there were no residents at the facility under CCRC agreements. On 3/20/23, LPA KN interviewed the Administrator, who stated that the facility is not a CCRC. Based upon resident and Administrator interviews the facility did not adhere to the H&SC code indicating that the residents shall have a right “to live in an environment that enhances personal dignity.” Report Continued on LIC 9099C... Allegation: Facility interfering with residents exercising rights – Substantiated On 3/20/23 LPA KN interviewed the RP who stated that R13 was informed by the facility that R13 would need to be moved from an Independent to an Assisted Living Unit, and was being required to sign a new Residence & Care Agreement. LPA observed that the original agreement generated under the previous licensee (and per the terms of the sale the current Licensee is required to adhere to original agreements) states that a new agreement was not required when transferring to Assisted Living. On the same date, LPA interviewed the Administrator who confirmed that R13 needed to be transferred and that a new agreement was required. LPA further found that R13 was moved from the Independent unit to a temporary Assisted Living unit due to refusal to sign a new agreement. This resulted in material misrepresentation made to a resident with an existing CCRC agreement. Deficiency is cited under the California Health and Safety Code listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted with, Business Office Manager Aryanna Henry. Appeal Rights and a copy of this report provided via email.the state’s words, verbatim · CDSS document, Feb 1, 2024 · control 15-AS-20230310131125

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1771.8(s)(2)(a) · Plan of correction due date: Feb 16, 2024

Complainant alleges that the Provider’s food service is insufficient and in violation of Health & Safety Code (H&SC) §1771.8(s)(a) which states that Provider “Failed to fulfill his or her obligations under continuing care contracts.” This requirement was not met as evidence by: Based on observation and record review, the licensee did not comply with the section cited above... AGPA JW found that the facility had changed and eliminated components of the food service without providing at least 30 days written notice, and that the Licensee Provider had not held a meeting 60 days prior to adjustments in “policies, programs, or services that would materially change the operation or environment of the community as required by the Health & Safety Code and CCRC requirements.”the state’s words, verbatim · CDSS document, Feb 1, 2024

Plan of correction: POC: addendum to Plan of Operation describing how they will meet the H&SC code requiring formal written notice and/or meetings 60 days in advance of changes. POC must be submitted to CCLD by: 2/16/24

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1793.2(s) · Plan of correction due date: Feb 16, 2024

Complainant alleges that the Provider stopped providing security personnel as provided in the Residence and Services Agreement which was a violation of Health & Safety Code (H&SC) §1793.21(s) which states that Provider “Failed to fulfill his or her obligations under continuing care contracts.”. This requirement was not met as evidence by: Based on observation and record review, the licensee did not comply with the section cited above... The interviews were held as listed above. The following documents were reviewed: • February 28, 2023 email from ED to residents • Front Desk calendar for March 2023 • Approved Residence and Services Agreements from Methodist Homes and Lake Park Senior Livingthe state’s words, verbatim · CDSS document, Feb 1, 2024

Plan of correction: POC: security agency re-established covering (which hours); and self certify re-reviewing the original CCRC contract and understanding that 24 hour security guard service is to be covered. POC must be submitted to CCLD by: 2/16/24

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1793.21(c)(2) · Plan of correction due date: Feb 16, 2024

Health & Safety Code (H&SC) §1793.21(c)(2) which states residents shall have a right “To live in an environment that enhances personal dignity, maintains independence, and encourages self-determination. This requirement was not met as evidence by: The interviews were held as listed above. The following documents were reviewed: • Approved Residence and Services Agreements from Methodist Homes and Lake Park Senior Living Based on interviews with the residents during the December 29, 2022 Town Hall meeting and on separate occasions the ED at the time informed residents that the community was not a continuing Care Retirement community.the state’s words, verbatim · CDSS document, Feb 1, 2024

Plan of correction: POC: new/current Admin self certify reading the Personal Rights Regulations (insert RCFC personal rights regulation, and H&SC 1771.7(c)(2), understands them and will adhere to them. POC must be submitted to CCLD by: 2/16/24

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1793.21(t) · Plan of correction due date: Feb 16, 2024

Health & Safety Code (H&SC) 1793.21(t) The department, in its discretion, may condition, suspend, or revoke any permit to accept deposits, provisional certificate of authority, or certificate of authority issued under this chapter if it finds that the applicant or provider has done any of the following: (t) Made material misrepresentations to depositors, prospective residents, or residents of a continuing care retirement community. This requirement was not met as evidence by: Based on interviewed: A resident who lived in a residential living units (RLUs) needed to move to an Assisted Living Units (ALU) and was being to asked to sign new Residence & Care Agreements even though the original agreement with Methodist was in effect and that agreement did not require residents to sign a new admission agreements when moving to an ALU. This resident was housed in a temporary ALU and he and his family were told by the ED that he would not be moved to a permanent unit until a new agreement was signed.the state’s words, verbatim · CDSS document, Feb 1, 2024

Plan of correction: POC: new/current Admin self certify reviewing the original CCRC contract and H&SC 1793.21(t), and understands and will adhere to them. POC must be submitted to CCLD by: 2/16/24

Allegation investigated: Staff do not maintain facility in good repair

On 12/13/2023 at 11:05 AM, Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to conduct a complaint visit. LPA met with Buisness Office Manager Aryanna Henry and Executive Director Annemarie Domizio joined later. During the initial 10-day complaint visit. LPA interviewed staff, and collected documents. Staff 1(S1) stated that there was a known heating issue within the building and the administrative team has been working to correct it. The parts to fix the boiler had been ordered on 11/07/2023,and were rejected by the ownership group. They were then told that because there was an outstanding balance on the corporate account that the H-Vac technician would not service any of their facilities until that was resolved. The facility decided to contact a different company who scheduled the repairs for December 14, 2023. S1 also stated this heating issue is not affecting the whole building and heaters available for anyone whose room is affected. Continued on LIC 9099-C... Unsubstantiated ... Continued from LIC 9099 Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Dec 13, 2023 · control 15-AS-20231205100808

Allegation investigated: Facility staff does not ensure planned activities are posted in a readily accessible location for residents

On 10/24/23 at 3:12PM, Licensing Program Analyst (LPA) conducted an unannounced complaint visit, met with executive director (ED), gathered information and delivered investigation finding of above allegation. Allegation: Facility staff does not ensure planned activities are posted in a readily accessible location for residents Investigation Finding: Unsubstantiated During investigation, LPA toured the facility with ED and observed the glass encased poster displays for monthly planned activities were visibly accessible for public viewing (see 812 for more details). Continued on next page, LIC 9099-C Unsubstantiated ED stated that printed monthly planned activities are distributed directly to the residents a week prior to the start of the month's activities so residents can look over the schedules and sign up in advance for outings or preferred events. LPA also observed additional hard copies of the monthly planned activities were readily accessible at the front desk for residents' use. ED showed a binder of the monthly activities for residents that is also left at the front desk for residents' perusal if desired. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff does not ensure planned activities are posted in a readily accessible location for residents and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff does not ensure planned activities are posted in a readily accessible location for residents is unsubstantiated. No deficiency cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 24, 2023 · control 15-AS-20231017135613

Type of visit: Case Management - Other

On 10/24/23 at 3:43PM, while at the facility for another reason, Licensing Program Analyst (LPA) toured the facility with executive director (ED) who stated that since the original structural and electrical configurations remained the same, no construction permits were required. ED shared a copy of facility sketch with LPA during visit (see 812 for details). ED stated that remodelled areas were sectioned off to ensure residents are not impacted by the renovations. ED stated they secured a permit for the new bathroom tiles (see 812 for more details). LPA observed new flooring, paint, furnitures and fixtures on the first, second and 12th floors. LPA observed facility to be clean, bright and in good repair. No deficiencies cited during inspection. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 24, 2023