Marymount Villa Retirement Center

Allegation investigated: A resident sustained unexplained injuries while in care. Staff did not notify resident's responsible party of an incident.

On 8/17/2026 at 9:30 am, Licensing Program Analyst (LPA), Y. Brown arrived unannounced to deliver complaint findings for the allegations above. LPA met with Dolly Rizvi, Executive DIrector and explained the purpose of the visit. The Department’s investigation included but was not limited to interviews with 3 residents, 7 staff, 4 witnesses and reviewed records. The Department also collected records, including medical records from Alameda Health Systems and a copy of the San Leandro Police Department (SLPD). R1’s LIC602 (Physician’s Report), Face sheet, Prescribed Medication Dispensement Log, Caregiver Endorsement Notes, Incident reports and employee roster were also reviewed and copies obtained. LPA obtained and reviewed R1's face sheet, progress notes, and incident report. LPA also obtained and reviewed email documentation. Continued to LIC9099-C. Unsubstantiated Continued from LIC9099. Allegation: A resident sustained unexplained injuries while in care. Finding: Unsubstantiated The Department conducted staff interviews and S1, S2, S3, S4 and S5 corroborated with W3’s statement that R1 had some scattered scabs and areas of skin breakdown and R1 has a history of skin breakdown and struggled with behaviors of aggression and would hit their body on surrounding furniture when they got upset. Staff stated that R1 would become combative and aggressive, but staff would try to calm R1 and redirect, preventing R1 from self-harm. Staff denied hurting or causing any injuries to R1. Interviews with R2, R3, and R4 revealed that they have never witnessed or experienced any injuries from staff. Based on interviews and record review, there is a lack of evidence to conclude that R1 sustained unexplained injuries while in care. Based on the investigation, S1 stated that R1 was taken to the San Leandro Hospital on 11/6/2025, due to increased agitation and aggressive behaviors toward staff. Review of R1’s discharged record of 11/18/2025 received from Alameda Health Systems, indicated that R1’s observed bruises, “were scattered shin scabs and skin breakdown on Bilateral Upper Extremities (BUE) likely from fragile, atrophic skin from age.” Allegation: Staff did not notify resident's responsible party of an incident. Finding: Unsubstantiated During record review, LPA observed that R1 had a previous conservator but obtained a new conservator on 11/3/2025. LPA reviewed email correspondence on 11/4/2025 between the facility and the current conservator being notified of R1's pre existing conditions and R1 being sent to the hospital on 11/6/2025. 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. Exit interview conducted with Dolly and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 17, 2026 · control 15-AS-20251106165249

Allegation investigated: Staff do not provide activities to residents in care Staff are placing restrictions on visitations for residents Staff did not received a completed medical assessment before acceptance of resident Staff will not allow resident to leave the facility unassisted

On 7/8/2026 at 10:00 am, Licensing Program Analyst (LPA) Y. Brown arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegations above. LPA met with Dolly Rizvi, Executive Director and explained the purpose of the visit. During the investigation, LPA interviewed staff (S1, S2, S3, and S4) and Residents (R1,R2, R3 and R4). LPA toured the facility and obtained and reviewed the facilities LIC500 (Personnel Record) and resident roster. LPA reviewed and obtainted R1's LIC602 (Physicians Reports), Face Sheet, Care Plan/ LIC625 (Appraisal Needs and Services Plan), and Physican Fax Letter. Allegation: Staff do not provide activities to residents in care Finding: Unsubstantiated Continued on LIC9099-C. Unsubstantiated Allegation: Staff will not allow resident to leave the facility unassisted Finding: Unsubstantiated During record review, LPA observed that R1's LIC602 dated 5/8/2025 and 2/23/2026 stated that R1 "can not leave the facility unassisted." Interviews with staff revealed that they followed these guidelines and did not allow R1 to leave the facility unassisted. LPA observed that R1's most recent and updated LIC602 dated 4/17/2026, stated that R1 "can leave the facility unassisted." Interviews with staff revealed that since they received the new medical assessment they do not deny R1 from leaving the facility unassisted. Interview with R1 revealed that in the past staff did not allow them to leave unassisted but with the new updated medical assessment they are able to leave unassisted. LPA reviewed the Resident sign out sheet and observed that R1 has signed out multiple times and has been leaving the facility unassisted since the new medical assessment dated 4/17/2026. Based on interviews, record review and observations conducted, the above allegations are unsubstantiated. Although the allegations may have happened or is 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 cited. Exit Interview conducted with Dolly and copy of this report provided. Continued from LIC9099. During facility tour, LPA observed that the facility has a white board in the dining hall/common area that details the activities for the day. LPA observed residents attending the scenic drive that was scheduled for 10:00 am and the movie time that was scheduled at 1:30 pm. During record review, LPA reviewed the activities calendar. Interviews with residents revealed that the facility offers a variety of activities. R1 stated that the facility offers bingo and outings. R3 stated that the facility has a lot of activities such as walking, bingo, and movies. R4 stated that the facility offers different activities everyday. Interview with S2 revealed that the facility offers a variety of activities and there is a resident council meeting (every 3 months) where residents can bring up suggestions for new activities. Allegation: Staff are placing restrictions on visitations for residents Finding: Unsubstantiated During investigation, LPA reviewed the house rules that states that visitation hours are from 8:00 am-8:00 pm. Interview with S1 revealed that the facility previously had the COVID visitation policy posted but the restrictions on visitors are not being enforced. LPA observed that the COVID policy was not posted during visit. Interview with S2, S3, and S4 revealed that the facility does not enforce the previous COVID policy and they enforce the house rules visitation policy. Interviews with staff stated that if visitors want to visit before 8:00 am or after 8:00 pm, they just have to let the front desk know and the staff will accommodate them. Interviews with staff revealed that they deny placing restrictions on visitations for residents. Interview with residents revealed that their visitors are not restricted and are allowed to visit them at any time. Allegation: Staff did not received a completed medical assessment before acceptance of resident Finding: Unsubstantiated During record review, LPA observed that R1 was admitted to the facility on 5/13/2025. LPA reviewed R1's LIC602 and observed that it was dated on 5/8/2025 before R1 was admitted. Interview with S1 revealed that R1 did receive a medical assessment before being admitted. Interview with R1 revealed that they obtained a medical assessment before moving in.the state’s words, verbatim · CDSS document, Jul 8, 2026 · control 15-AS-20260702105209

Allegation investigated: Staff interfered with resident visitation

On 5/15/2026 at 9:30 am, Licensing Program Analyst (LPA) Y. Brown arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegation above. LPA met with Bessy John, Care Coordinator and informed the reason for visit. During the investigation, LPA interviewed 4 residents, 4 staff members, and W1, W2 and W3. LPA obtained and reviewed the following resident documents: Care Plan, Emergency Information and Contact, Admission Agreement, LIC602 (Physician's report), and Appraisal Needs and Services Plan. Continue to LIC9099-C. Unsubstantiated Continued from LIC9099. Allegation: Staff interfered with resident visitation Finding: Unsubstantiated During investigation, LPA conducted interviews with W1, W2, W3, residents, staff and reviewed R1’s documents. Review of R1’s admission agreement dated 11/13/2023 showed that the visitation hours are 7 days a week from 9AM to 7PM. S1 stated that W1 has come to the facility to see R1 but not during visitation hours. S2 stated that W1 has come to the facility at 6am or even at 8pm (not sure on exact dates). W1 stated that they have come to the facility to visit R1 but not during visitation hours due to their work schedule. W1 stated that the facility has accommodated W1 with seeing R1 not within the visitation hours. S1, S2, S3, S4, and W1 stated that R1 has a roommate. S2 stated that for all residents, if a resident has visitors but they have a roommate, the visitors are still allowed to visit them in their room, but the visitors do have a limit on how long they can be in the room out of respect for their roommate. Based upon the interviews and record review conducted during the investigation, the above allegation is 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 with Bessy and a copy of report provided.the state’s words, verbatim · CDSS document, May 15, 2026 · control 15-AS-20251223190548

Allegation investigated: Staff did not prevent inappropriate interaction between two residents.

On 5/1/2026 at 9:15 am, Licensing Program Analyst (LPA) Y. Brown arrived unannounced to conduct an initial 10-day complaint investigation in regards to the allegation above. LPA met with Bessy John, Care Coordinator and informed the reason for visit. During investigation, LPA obtained the following documents for Resident (R1 and R2): Face Sheet, Care Plan, Appraisal Needs and Services Plan and LIC602(Phsyicians Report). LPA also obtained a copy of the incident report dated 4/10/2026. LPA conducted interviews with Staff (S1, S2 and S3) and residents (R1, R2, R3 and R4). Continue to LIC9099-C. Unsubstantiated Continued from LIC9099. Allegation: Staff did not prevent inappropriate interaction between two residents. Finding: Unsubstantiated Interview with RP revealed that R1 stated that R2 had touched R1 on the shoulder and hand. Interview with staff revealed that this incident between R1 and R2 happened on 4/7/2026. S2 stated that they witnessed R2 walk past R1 in the common area and touched R1 on their shoulder and said "hello." S2 stated that they immediately redirected R2 away from R1 and took R2 outside. S1 stated that staff checked on R1 and made sure R1 was okay. Interview with R1 revealed that R2 touched their shoulder and hand and said "hello." R1 stated that S2 intervened immediately and separated R2 from R1. R1 stated that they feel safe living at the facility. R1 stated that R2 has not touched them again. LPA reviewed R1 and R2's appraisal needs and services plan and it indicated that R1 and R2 do not need a 1:1 staff person assigned to them. LPA observed that the facility contacted the resident responsible parties and implemented preventative measures. 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 is UNSUBSTANTIATED. No deficiencies are being cited on this date. Exit interview conducted with Bessy John. A copy of this report provided.the state’s words, verbatim · CDSS document, May 1, 2026 · control 15-AS-20260428120943

Type of visit: Case Management - Health Checks

On 1/28/2026, at 11:00 AM, Licensing Program Analysts (LPAs), Y. Brown and P. Manalo arrived unannounced conduct a case management health and safety check. LPAs met with Dolly Rizvi, Administrator. LPAs toured the facility with the care staff including but not limited to residents' apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Continue on LIC809C. Continued from LIC809. The Following Deficiencies were observed during visit: At 10:41 am, LPAs observed that the cabinet in the common area on level 3 is missing a handle, dresser and floor in room 315 is in disrepair. At 10:51 am, LPAs observed that there were disinfectants and cleaners like Lysol sprays, Petroleum Jelly, Razor, and A+D Ointment, in an unlocked cabinet in the common area. At 10:55 am, the water temperature was measured at 95.7 degrees Fahrenheit in a random sample of residents shared bathrooms Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (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 Dolly Rizvi and a copy of the appeal rights and this report provided.the state’s words, verbatim · CDSS document, Jan 28, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Jan 29, 2026

87309 Storage Space and Access (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in that disinfectants and cleaners like Lysol sprays, Petroleum Jelly, Razor, and A+D Ointment, were in an unlocked cabinet in the common area where residents have access which poses an immediate safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 28, 2026

Plan of correction: By POC date, the administrator agrees to remove the disinfectants and cleaners like Lysol sprays, Petroleum Jelly, Razor, and A+D Ointment and send photo proof to CCLD.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87309 · Plan of correction due date: Feb 4, 2026

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 is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in that the cabinet in the common area on level 3 is missing a handle, dresser and floor in room 315 is in disrepair, which poses a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 28, 2026

Plan of correction: By POC date, the administrator agrees to repair the missing handle cabinet and the dresser and floor and send photo proof to CCLD.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(e)(2) · Plan of correction due date: Feb 4, 2026

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2)Faucets used by residents for personal care such... attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidence by: Based on observation, the licensee did not comply with the section cited above in that the water temperature was measured at 95.7 degrees Fahrenheit in a random sample of residents shared bathrooms which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 28, 2026

Plan of correction: By POC date, the administrator agrees to adjust the water temperature and send photo proof to CCLD.

Type of visit: Case Management - Incident

On 1/6/2026 at 12:45 PM, Licensing Program Analysts (LPAs) Y. Brown and A. Gomez arrived unannounced to conduct a Case Management visit in regards to an unusual incident report received 1/5/2026. LPAs met with Executive Director, Dolly Rizvi, and explained the purpose of the visit. It was reported that on 12/31/2025 resident (R1) eloped from the facility. At approximately 4:18 pm, the front desk received a call from R1's POA about R1 leaving the facility. R1 was located at a shopping center. Staff picked up R1 and brought R1 back to the facility. During visit LPAs reviewed R1's physicians report and care plan. LPAs also contacted R1's physicians that stated that R1 is not able to leave unassisted. The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalties. Exit interview conducted with Dolly Rizvi appeal rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Jan 6, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87219(i) · Plan of correction due date: Jan 7, 2026

87219 Planned Activities (i) The licensee shall implement reasonable interventions in order to ensure the safety of all residents utilizing indoor and outdoor areas and take precautions to prevent residents from unsafe wandering and elopement, as defined in Section 87101, Definitions. Such precautions may not conflict with residents' personal rights as specified in Section 87468.1, Personal Rights of Residents in All Facilities and Section 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities. This requirement is not met as evidenced by: Based on record review and interviews, the facility did not meet the requirement above by staff neglecting to ensure that R1 who is a memory care resident was being supervised during group activities with assisted living residents in the common area which led to R1's elopement. There was also not a process in place to assure residents safety during activities which posed an immediate safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 6, 2026

Plan of correction: By POC date, the Licensee agrees to coordinate all staff to complete training regarding care and supervision of dementia residents through a CCLD approved vendor and submit proof to CCLD. The facility also agrees to develop and implement a plan to ensure residents safety during activities and notify CCLD.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87411(a) · Plan of correction due date: Jan 13, 2026

Personnel Requirements-General 87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section above by not having sufficient and competent number of staff to meet R1's care needs. Executive Director states that staff were not aware of R1's elopement and they did not complete head counts until after the activity which resulted in R1 having eloped for approximately 40 minutes before the facility was aware which is a potential safety and personal rights risks to residents in care.the state’s words, verbatim · CDSS document, Jan 6, 2026

Plan of correction: By POC date, the Licensee agrees to update LIC500 to ensure adequate staffing for all shifts and all staff will receive an in service training and notify CCLD.

Allegation investigated: Staff are physically abusing resident in care. Staff are emotionally abusing resident in care.

On 12/29/2025 at 2:00 PM, Licensing Program Analysts (LPAs) Y. Brown and G. Luk arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegations above. LPAs met with Executive Director, Dolly Rizvi and informed her the reason for visit. During investigation, LPAs obtained and reviewed the following documents: Resident Roster and the LIC500 (Personnel Report). LPAs also collected and reviewed the following documents for Resident one (R1, R2 and R3): Progress notes (September-November 2025), Incident Reports (September-November 2025), LIC602 (physician's report), Appraisal Needs and Services Plan, Identification and emergency contact form and staff Contact Information. LPAs interviewed six (6) residents and four (4) staff members. Continued on LIC9099-C. Unsubstantiated Allegation: Staff are physically abusing resident in care. Finding: Unsubstantiated Based on the investigation, interviews with staff revealed that they have not witnessed or heard about any staff members physically or emotionally abusing any residents in care. Interviews with residents reveal that they have not experienced any staff members physically or emotionally harming them or others at the facility. Allegation: Staff are emotionally abusing resident in care. Finding: Unsubstantiated Based on interviews with residents, it was revealed that they have not experienced any staff members emotionally abusing them or witnessed any staff members emotionally abusing any residents. Interviews with staff revealed that they have not witnessed or heard about any staff members emotionally abusing residents in care. 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 are UNSUBSTANTIATED. No deficiencies are being cited on this date. Exit interview conducted with Dolly Rizvi and a copy of this report provided.the state’s words, verbatim · CDSS document, Dec 29, 2025 · control 15-AS-20251112180321

Allegation investigated: Licensee is financially abusing resident in care.

On 12/29/2025 at 12:00 PM, Licensing Program Analysts (LPAs) Y. Brown and G. Luk arrived unannounced to conduct complaint investigation and to deliver complaint findings for the allegation above. LPAs met with Executive Director, Dolly Rizvi and explained the purpose of the visit. During the investigation, LPAs collected the following documents: the facilities LIC 500 and residents roster. LPA also obtained and reviewed Resident one's (R1's) LIC602 (Medical assessment), Progress notes, Eviction Notice, admissions agreement, Invoice of room fees, Incident reports (month of July-December 2025), Pre-admission appraisal and Appraisal Needs and Services Plan. LPAs interviewed the Complainant, staff, and W1. Continued to LIC9099-C. Unsubstantiated Continued from LIC9099. Allegation: Licensee is financially abusing resident in care. Finding: Unsubstantiated Based on interviews with staff and W1 revealed that R1 receives monthly income from Supplemental Security Income (SSI) and the remaining income was provided by the family. Interview with complainant indicated that R1 was being charged private room rate when R1 did not request to be in a private room. There was a lack of evidence that licensee is financially abusing R1. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies are being cited on this date. Exit interview conducted with Dolly Rizvi and a copy of this report provided.the state’s words, verbatim · CDSS document, Dec 29, 2025 · control 15-AS-20251215162420

Type of visit: Case Management - Deficiencies

On 12/29/2025 at 12:00PM, Licensing Program Analysts (LPAs) G. Luk and Y. Brown arrived unannounced to conduct a case management visit. LPA met with Executive Director, Dolly Rizvi and explained the purpose for the visit. While LPAs were at the facility for a complaint investigation (#15-AS-20251215162420), the following deficiencies were observed. LPAs observed eviction notice issued to R1 on 11/13/2025 did not specify what care needs the facility was unable to provide to R1. LPAs observed facility did not provide 90 days written notice to R1 or R1's family regarding R1's increase rate. An email was sent on 11/26/2025 regarding R1's rate increase for December 2025. The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and Health & Safety Code. Failure to correct deficiencies may result in civil penalties. Exit interview conducted with Dolly Rizvi. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Dec 29, 2025

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.655(a) · Plan of correction due date: Jan 5, 2026

1569.655 Increase in fee rates for elderly residents; 90 days’ written notice...(a) If a licensee of a residential care facility for the elderly increases the rates of fees for residents or makes increases in any of its rate structures for services, the licensee shall provide no less than 90 days’ prior written notice to the residents or the residents’ representatives... This requirement is not met as evidience by: Based on record review, licensee did not comply with the section cited above by not providing 90 days written notice for increase rate which poses a potential health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, Dec 29, 2025

Plan of correction: Executive Director (ED) has agreed to send an email to rescind the rate increase and submit a copy of the email to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87224(a)(4) · Plan of correction due date: Jan 5, 2026

Eviction Procedures. (a) The licensee may evict a resident for one or more of the reasons listed... (4) If, after admission, it is determined that the resident has a need not previously identified and a reappraisal has been conducted pursuant to Section 87463, and the licensee and the person who performs the reappraisal believe that the facility is not appropriate for the resident. This requirement is not met as evidence by: Based on record review, the licensee did not comply with the section cited above by not providing an explanation in the eviction notice which poses a potential health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, Dec 29, 2025

Plan of correction: Executive Director (ED) has agreed to revise the eviction notice for R1 and submit the revised letter to CCLD by POC date.

Type of visit: Case Management - Health Checks

On 11/7/2025, at 2:45 PM, Licensing Program Analysts (LPAs), Y. Brown and L. Hall arrived unannounced conduct a case management health and safety check. LPAs met with Bessy John, Care Coordinator. LPA toured the facility with the Bessy John, Care Coordinator, including but not limited to residents' apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. There are no imminent health/safety concerns on today's date. No deficiencies cited during the Health and Safety visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 7, 2025

Allegation investigated: Due to lack of supervision, a resident physically assaulted another resident, resulting in injury and hospitalization. Resident in care was diagnosed with severe dehydration. Staff did not assist resident with feeding.

On 11/16/2025 at 10:15AM, Licensing Program Analyst (LPA) Carol Fowler and David Doidge arrived unannounced to deliver complaint findings for the allegations above. Upon arrival, LPA met with Executive Director, Dolly Rizvi and explained to her the reason for the visit. During the investigation LPA reviewed two (2) resident files, conducted three (3) staff interviews. LPA reviewed and received the following documents for R1: Fact Sheet, ID & Emergency Form, Physician's Report, Progress Notes, Food and Liquid Chart and Resident Care Plan. LPA also reviewed and received the following documents for R2: Fact Sheet, Residents Plan of Care, ED notes, Appraisal Needs and Service Plan, and Physician's report. Unsubstantiated CONTINUE FROM LIC9099 Allegation: Due to lack of supervision, a resident physically assaulted another resident resulting in injury and hospitalization Investigation Finding: Unsubstantiated The Department interviewed R1, R2, S2, S1, S3, S4, and S5. Staff reported that during lunch service, R1 was heard screaming from R1s room, and that Staff immediately responded. S4 stated seeing R2 leaving R1s room, then found R1 on the floor with blood and what appeared to be defensive wounds. Per Staff, R1 reported that R2 was in her room and in her closet when R1 attempted to stop R2, whereby both had struck the other. R1 had fallen backwards. R2 was unable to provide information related to the event. Review of a police report responding to the incident showed that there was no determination as to whether an assault had taken place or if R1 had an unwitnessed fall. R1 was immediately transferred to hospital where it was found that R1 had sustained a fracture, a cut above the eyebrow, and bruising. Hospital records indicate that R1 also had a back injury. It was indeterminate when that injury took place and it was noted that it could have been associated with R1s overall condition. A review of R1’s file did not indicate that R1 was a fall risk, and there was no record to indicate a history of falling at the facility. There was also no information to suggest that R1 had displayed a history of aggression. The Needs and Services Plan and the Physician’s report had no information to indicate that R1 needed additional supervision. A review of R2’s file indicated a history of aggression towards staff, but had no information to indicate known aggression towards other residents. There was no indication of R2 needing additional supervision, or a 1:1 caregiver. All staff interviewed stated having no knowledge of R2 having a behavior of aggression towards other residents. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur. Therefore, the allegation is Unsubstantiated. CONTINUE FROM LIC 9099 Allegation: Resident In care was diagnosed with severe dehydration Investigation Finding: Unsubstantiated Interviews and record review (R1’s care notes) revealed that R1 was provided water, ensures, and juices. Charting shows that R1 was drinking the liquids that were provided to R1, however charting also revealed that R1 would on some occasions skip the ensure but would drink the water and juices provided. Interview with S1 revealed that R1 drank beverages on R1 own and was vocal about what drinks R1 wanted, and staff would provide and chart. Interview with S2 revealed that R1 loved coffee and would drink beverages on R1s own and that staff would measure intake. Interview with S3 revealed that R1 would drink beverages on R1s own and staff kept track of R1s intake. Interview with S4 revealed that R1 would drink beverages on R1s own and that staff would keep track on R1s intake. The Department obtained and reviewed R1s hospitalization report and there was no information to indicate that the resident had been dehydrated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur. Therefore, the allegation is Unsubstantiated. CONTINUE FROM LIC9099 Allegation: Staff did not assist resident with feeding Investigation Finding: Unsubstantiated Interviews and record review revealed that R1 is able to feed self. Review of R1’s physician report shows that R1 is able to feed self. Interview with S1 revealed that R1 ate on own. Staff would prepare the food and bring it to R1 but staff never assisted with feeding. S1 stated that R1 also liked extra snacks and food and would eat on R1’s own. Interview with S2 revealed that R1 ate on R1s own and no one had to assist R1 with feeding. S2 also stated that staff would ask R1 if R1 wanted snacks and R1 would eat them all. Interview with S3 revealed that R1 would feed R1 self and staff would keep track of how much R1 ate and drank and that R1 ate normal portions and would give snacks and R1 would eat them and loves coffee. Interview with S4 revealed that R1 would eat all food in R1s room on R1’s own and that the facility provided R1 with water, ensure, coffee and tea and R1 would eat and drink normal portions. S4 stated that staff has never fed R1, R1 and without assistance. A review of the Needs & Services plan and the Physician’s report indicated that R1 is capable of feeding self. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur. Therefore, the allegation is Unsubstantiated. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove it; therefore, the allegations are UNSUBSTANTIATED. No deficiency was cited during this visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 6, 2025 · control 15-AS-20250325094655

Type of visit: Case Management - Incident

On 10/14/2025 at 12:00 pm, Licensing Program Analyst (LPA) Y. Brown conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 9/18/2025. LPA met with Dolly Rizvi, Administrator, and explained the purpose of the visit. The incident occurred on 9/16/2025. Incident report stated that R1 became non responsive. R1 was previously being seen at the facility by Home Health due to unstageable wounds. LPA reviewed R1's care plan and interviewed S1. Although R1 was seen by home health professionals who cared for the wounds, licensee failed to obtain exception request and have it approved prior to retaining R1 back to the facility. The documents that were obtained showed that R1 had unstageable wounds on 8/27/2025 and stage 4 wounds on 9/3/2025, while still residing at the facility. The document obtained from the hospital stated that R1 was discharged on 9/17/2025. S1 stated that R1 was placed on hospice on 9/24/2025. The deficiency was 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 right provided.the state’s words, verbatim · CDSS document, Oct 14, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87612(a)(11) · Plan of correction due date: Oct 15, 2025

87612 Restricted Health Conditions (a) The licensee may provide care for residents who have any of the following restricted health conditions, or who require any of the following health services:(11) Wound care as specified in Section 87631. Based on files review and interview the Licensee did not comply with the section cited above by R1 having an unstageable wound residing in the facility, which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 14, 2025

Plan of correction: By POC date, Administrator will inform licensing, and submit all require documents regarding wound care and updates reports any wound residents developing, or return back to facility upon wound care. Review the cited regulation with a self-certification understanding regulation, fax all documents to CCLD.

Type of visit: Required - 1 Year

On 10/14/2025 at 10:00 AM, Licensing Program Analysts (LPA) Y. Brown arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator (ADM), Dolly Rizvi, and explained the purpose of the visit. The facility’s fire clearance was approved for ninety nine (99) non-ambulatory residents, of which nine (9) may be bedridden and approved for eighteen (18) hospice. LPA toured the facility with the ADM, including but not limited to residents' apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in a sample of resident's bathrooms were measured at 112.1,113.1, and 110.6 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher all around the facility was last serviced on 10/16/2024. LPA reviewed six (6) staff and seven (7) resident records. LPA reviewed a sample of medication. Continued on LIC809C. Continued from LIC809. The following forms will be updated and submitted to CCLD by 10/21/2025: LIC610D: Emergency disaster plan The following deficiency was observed: At 1:00 pm, LPA observed missing first aid training from 0/5 staff members. Deficiency was cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (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. A copy of the appeal rights and this report provided.the state’s words, verbatim · CDSS document, Oct 14, 2025

Allegation investigated: Staff did not make resident's records available to their designated representative upon written consent

On 09/24/2025 at 4:30 PM, Licensing Program Analyst (LPA) L. Alexander conducted a subsequent visit and met with Executive Director (ED) Dolly Rizvi to deliver the findings of above allegation. LPA explained the purpose of the visit with ED. During investigation, the LPA obtained the following documents from the facility – Residents Listing, Staff Roster, Resident (R) R1's Admissions Agreement, R1's Face Sheet, copy of email (dated 06/26/25), copy of R1's Durable Power of Attorney for Financial Management (dated 05/20/23), copy of California Advance Health Care Directive (dated 05/20/23), copy of R1's Assisted Living Waiver Informing Notice (dated 11/26/24), R1's Physician's Report, care notes, incident reports and Copy of Policy Procedures for Medical records. LIC9099-C Continued... Substantiated LIC9099-C (Page 2) Allegation: Staff did not make resident's records available to their designated representative upon written consent Finding: Substantiated On 07/01/2025, Licensing Program Analyst (LPA) L. Alexander interviewed Witness (W1). W1 stated that on 06/04/2025, they submitted a request for R1’s file via fax. After allowing one week for acknowledgment, W1 followed up with the facility on 06/11/2025 by emailing the authorization and status request to Staff (S2) and leaving a voicemail message. W1 reported no response was received. W1 confirmed that R1 was a former resident of the facility. On 07/02/2025, LPA interviewed Staff (S1). S1 confirmed a faxed request was received but stated they were unsure which document W1 was referring to due to the volume of faxes. S1 stated that per facility policy, once a resident leaves the facility, S2 is responsible for reviewing and releasing records. LPA reviewed the following documents: Authorization to Handle Claim (05/29/2025), Authorization to Release Medical Documents (06/04/2025), Durable Power of Attorney for Financial Management (05/20/2023), Advance Health Care Directive (05/20/2023), Subpoena Request for Medical Records (06/04/2025), and the facility’s Policy for Release of Resident Records. Documentation verified that R1’s legally authorized representative was acting on R1’s behalf. On 09/14/2025, S1 confirmed the requested records had been sent. On 09/15/2025, LPA followed up with W1, who confirmed the records were received on 08/19/2025—approximately two months after the initial request. The preponderance of evidence demonstrates that the facility did not release records within a reasonable or timely manner. Therefore, the allegation is substantiated. LIC9099-C Continued... LIC9099 (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 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. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 24, 2025 · control 15-AS-20250627153453

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(19) · Plan of correction due date: Oct 8, 2025

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities...the elderly shall have all of the following personal rights: (19) To have prompt access to review all of their records...records shall be provided within two (2) business days... This requirement was not met as records requested on 06/04/2025 were not released until 08/19/2025. Based on record review and interviews, the licensee did not comply with the section cited above in by not submitting requested former resident's, R1's, records to law firm in a timely manner which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 24, 2025

Plan of correction: Administrator shall submit a written detailed plan describing corrective action to ensure record requests including but not limited to current residents, former residents, authorized representatives and law firms for pending lawsuitsare processed and provided within regulatory timeframes and submit to CCLD by POC due date.

Allegation investigated: Staff will not allow accept resident at facility

On 08/27/2025 at 10:30 AM, Licensing Program Analysts (LPAs), Y. Brown and C. Fowler arrived unannounced to deliver a complaint finding for the allegation above. LPAs met with Administrator Dolly Rizvi and explained the reason for the visit. During the course of the investigation the Department conducted interviews with staff, witnesses, obtained and reviewed records. Allegation: Staff will not allow accept resident at facility During the investigation W1 was interviewed and stated R1 was admitted into Kaiser Medical Center San Leandro on July 30, 2025. W1 further stated when R1 was ready to be discharged that evening S1 stated facility will not accept R1 unless he had a private caregiver. W1 stated R1 was discharged on August 1, 2025, with a private caregiver that worked with R1 until August 4, 2025. Continued on LIC9099C. Substantiated Continued from LIC9099. During the interview with S1, S1 stated due to R1’s diagnosis R1 needed a private caregiver to keep him isolated and would not take him back into the facility without a private caregiver. S1 had spoken with Kaiser staff and R1’s responsible party. S1 stated R1’s responsible party refused to pay for a private caregiver. On August 1, 2025, R1 had a private caregiver provided by Kaiser and was transported back to the facility via ambulance. LPAs reviewed the facility’s infection control plan. On page 17 of the infection control plan it states “Hospital discharge and admission or re-admission to a facility should not be delayed or prevented due to the COVID-19 status of the patient.” Based on LPA's information obtained during 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.the state’s words, verbatim · CDSS document, Aug 27, 2025 · control 15-AS-20250731152150

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468(a)(4) · Plan of correction due date: Sep 18, 2025

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities [...] shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs [...] and competency to meet their needs. This requirement is not met as evidenced by: Based on interview, the licensee did not comply with the section cited above for not allowing R1 to return back to the facility due to the COVID-19 status of the patient which poses a potential safety risk to the persons in care.the state’s words, verbatim · CDSS document, Aug 27, 2025

Plan of correction: Administrator agreed to conduct in-service training for all employees regarding the infection control plan and submit sign-in sheet to CCLD by POC date.

Allegation investigated: Staff did not provide adequate supervision resulting in residents eloping.

On 08/1/25 at 11:00AM, Licensing Program Analysts (LPA) K. Nguyen and Y Brown conducted an unannounced complaint visit, met with Care Coordinator, Bessy John. LPAs spoke with Executive Director/Administrator (ED/ADM) via phone and received permission for Bessy to sign the report. LPAs explained the purpose of the visit with ADM. LPAs conducted interviews & record reviews and delivered investigation findings to Care Coordinator. Allegation: Staff did not provide adequate supervision resulting in residents eloping. Investigation Finding: Substantiated During investigation, LPAs interviewed S1,S2, S3,S4,and S5 and reporting party (RP). LPAs reviewed and requested staff and resident roster, and the following documents from resident's (R1 & R2) file: Physician's Reports, Appraisal Needs and Services Plan, and Police Report. Continued on next page, LIC9099-C Substantiated ...continued from LIC9099. Staff did not provide adequate supervision resulting in residents eloping. LPAs interviewed S3 and S3 stated that R1 and R2 were fighting with each other before S3 took the residents outside. S3 stated that they left R1 and R2 outside unattended while they went inside the facility. S3 stated that they went inside to tell the front desk that they were leaving the residents outside. S3 stated that "they forgot the residents outside" and S3 stated that they thought the residents "went inside themselves." S3 stated that "R1 and R2 like to be outside by themselves." S3 stated that "the staff got busy and didn't know where the residents went." LPAs reviewed R1 and R2's Physician's Report (LIC602) and it revealed that R1 and R2 are unable to leave the facility unassisted. Based on information obtained, the allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Exit interview conducted, appeal rights and a copy of this report provided to Bessy John.the state’s words, verbatim · CDSS document, Aug 1, 2025 · control 15-AS-20250728102149

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Aug 2, 2025

To care, supervision, and ...meet their individual needs...by staff that are sufficient in numbers, qualifications, and competency... This requirement was not met as evidence by: Based on interview and record review, the licensee did not comply with the section cited above in having R1 and R2 left unattended which resulted in residents eloping in which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 1, 2025

Plan of correction: Administrator will create a plan to implement a system that helps elopments reduce. Proof of correction will be sent to CCLD by POC date.

Allegation investigated: Facility staff blocks an exit doors presenting a hazard to residents

On 07/17/25 at 11:30AM, Licensing Program Analysts (LPA) D Panlilio and Y Brown conducted an unannounced complaint visit, met with Executive Director/Administrator (ED/ADM). LPAs explained the purpose of the visit with ADM. LPAs conducted interviews & record reviews and delivered investigation findings to ADM. Allegation: Facility staff block exit doors presenting a hazard to residents Investigation Finding: Substantiated During investigation, LPAs interviewed staff (ED/ADM) and reporting party (RP) who confirmed that on 07/07/25 and 07/11/25 the emergency exit doors on the 3rd, 4th and 5th floors were still blocked with a bench and a potted plant to prevent dementia residents from seeking an exit. ED/ADM stated that they conducted a fire safety in-service training with all staff on 07/11/25, 07/14/25 and 07/15/25. Continued on next page, LIC 9099-C Substantiated Based on LPA’s interviews and record reviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation(s) that facility staff block emergency exit doors presenting a hazard to residents was found to be substantiated. This is a repeat violation of Title 22 Section 87203 Fire Safety which was issued on 02/21/25. An immediate civil penalty of $500 is being assessed due to fire clearance violation. Deficiency is cited per Title 22 California Code of Regulations and 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. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 17, 2025 · control 15-AS-20250711145942

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Jul 17, 2025

All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not met as evidenced by staff failing to keep emergency exit doors unobstructed which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 17, 2025

Plan of correction: Deficiency cleared during visit on 07/17/25. ED/ADM completed n-service staff re-trainings on fire safety in compliance with Section 87203 on 071/1/25, 07/14/25 and 07/15/25. An immediate civil penalty of $500 is being assessed due to fire clearance violation.

Type of visit: Case Management - Deficiencies

On 07/17/25 at 12:30 PM, while at the facility for another reason, LPAs Y. Brown and D. Panlilio conducted a case management visit to discuss administrator duties (must be present at the facility for a minimum of 20 hours per week) and reporting requirements with Executive Director (ED) Dolly Rizvi. LPAs also discussed the Emergency/ Disaster Plans with ED/ADM and requested updated reviewed copies with dates and signatures during visit. LPAs advised ED/ADM to conduct monthly staff meetings and discuss fire safety/emergency/disaster procedures and timely reporting requirements. ED/ADM confirmed with LPAs that no incident reports were submitted to CCLD for the emergency exit blockages on the 3rd, 4th and 5th floors of the facility. Deficiency is cited per Title 22 California Code of Regulations and 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. Appeal Rights and a copy of this report Provided.the state’s words, verbatim · CDSS document, Jul 17, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a) · Plan of correction due date: Aug 11, 2025

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: This requirement is not met as evidenced by: -Based on interview with ED/ADM there were no incident reports submitted to CCLD for the emergency exit blockages on the 3rd, 4th and 5th floors of the facility which poses a potential safety and risks to person in care.the state’s words, verbatim · CDSS document, Jul 17, 2025

Plan of correction: By POC due date, ED/ADM agrees to complete and submit to CCLD in-serive staff retraining on reporting requirements and compliance with section 87211.

Allegation investigated: -Staff refused to accept resident (R1) back to the facility after an emergency (ER) visit. -Staff did not ensure that resident's (R1) bed was in working condition. -Staff did not ensure that resident (R1) was adequately fed.

On this day, April 24, 2025, at 1:00 p.m., Licensing Program Analyst (LPA) Delmundo conducted an unannounced visit to deliver the findings for the above allegations. LPA met with Executive Director (ED) Dolly Rizvi and informed the reason for visit. During the course of investigation, LPA obtained copies of resident roster and staff schedule, reviewed resident's file, and conducted interviews. LPA obtained copies of resident's following documents: Face Sheet; LIC602A Physician's Report; LIC625 Appraisal/Needs and Services Pan; Hospital After Visit Summary. LPA also obtained copies of staff's LIC501 Personnel Record. The following were interviewed: reporting party (R1) on 7/21/22; staff (S1) and ED on 7/27/22; resident (R1) on 7/27/22; staff (S2 and S4) on 4/23/25 ....continued on 9099C (page 2) Unsubstantiated Page 2 Allegation: Staff refused to accept resident (R1) back to the facility after an emergency (ER) visit. The reporting party (RP) stated that the facility administrator (ED) refused to accept R1 back to the facility due to a bed issue. The RP stated that R1’s semi electric bed which was brought to the facility from R1’s home was broken and unless R1 is provided with a replacement bed, either a hospital bed or another semi electric bed, ED won’t admit R1 back, and that ED said R1 has not eaten in 24 hours and has become agitated because of the bed being broken. ED denied the allegation that she refused to admit R1 back. ED stated the staff reported to her on 7/17/22 that the remote control of R1’s bed was broken and that R1’s daughters (FM1 and FM2) came to the facility on 7/18/22 and R1 was agitated because of the bed being broken and would not eat. R1 can feed self but would not want the staff put pillow to elevate/raise her head and was refusing to eat that day. ED also stated that she told the hospital several times to arrange the rental bed which will take only one hour, and that they can send the bill to the facility and the facility will get paid by the responsible party. ED further stated she told FM1 and FM2 they can rent a hospital bed temporarily, but the daughters were saying the insurance would not cover 100% of the cost. FM1 and FM2 told them to call 9-1-1 so R1 was sent out. R1 may also have UTI because R1 was very agitated that day. R1 was discharged back to the facility on 7/19/22. R1 stated not remembering what happened to her bed. LPA observed R1’s bed was working on 7/27/22. LPA tried to reach to FM1 and FM2 to obtain information, but they did not return LPA’s call. S1 and S4 confirmed ED’s statement that the remote control of R1’s bed was broken and that R1 was agitated and refusing to eat. S1 stated R1’s bed was broken on and off and the issue reported to R1’s daughters. S1 also stated that R1 was sent out on 7/18/22 and discharged back on 7/19/22. Hospital After Visit Summary showed R1 was admitted on 7/18/22 for feeding and behavior problems and discharged on 7/19/22. Based on information gathered and LPA unable to obtain information from FM1 and FM2, the allegation is unsubstantiated. ....continued on 9099C (page 3) Page 3 Allegation: Staff did not ensure that resident's (R1) bed was in working condition. S1 stated R1's bed has been on and off broken and R1’s daughters were informed and aware. Prior to the last time the bed was broken on 7/17/22, the daughter sent a motor to the facility and the motor of the bed was replaced. The bed was not a hospital bed, but part of the bed can be raised with a remote control. S4 confirmed that the remote control of R1’s bed was broken. During interview on 7/27/22, R1 was not able to provide information about her bed but stated she’s happy. LPA observed R1’s bed was working that day. LPA tried to reach to FM1 and FM2 to obtain information, but they did not return LPA’s call. Based on information gathered and LPA unable to obtain information from FM1 and FM2, the allegation is unsubstantiated. Allegation: Staff did not ensure that resident (R1) was adequately fed. S2 stated she fed residents during her shift and if residents refused to eat, she reported to her supervisor and facility nurse who gave her instructions what to do and she followed the instructions. S2 further stated they cannot force feed the residents, and that residents have right to refuse, but she came back and offer food 2 or 3x. She documented if resident still refused. S4 stated the caregivers were feeding R1. S4 also stated that R1 knew that R1 has medications that needed to be taken with food. S4 further stated that she does not remember any incident where caregivers refused and/or didn't feed R1. R1 stated she likes to eat dinner at 5:00 p.m. and dinner is already prepared at that time but was not able to provide information if caregivers refused to give her food. ....continued on 9099C (page 4) Page 4 Based on information gathered and LPA unable to obtain information from FM1 and FM2, the allegation is unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiency cited. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Apr 24, 2025 · control 15-AS-20220720121412

Allegation investigated: Staff did not clean resident's (R1) room.

On this day, 4/04/25, at 12:10 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the investigation and close the complaint. LPA met with staff, Duncan Agyemang and Ernesto Buendia. LPA called and spoke over the phone with Executive Director (ED) Dolly Rizvi, and informed the reason for visit. During the course of investigation, LPA obtained copies of of the following: November 2020, December 2020 and current resident rosters; November 2020, December 2020 and current staff schedules. Resident's (R1) family member (FM) stated that when R1 passed away in 2020, she was able to go to the facility on 12/26/2020 and collect R1's belongings. FM observed soiled clothes on the floor, soiled containers in the room and reddish liquid on the side of the bed, and that R1's room appeared not been cleaned for quite a while. Picture of the room was provided by FM. ....continued on 9099C (page 2) Substantiated Page 2 LPA conducted inspection on 10/14/21 and interviewed staff on 12/06/24 and 4/04/25. All three housekeepers interviewed stated that during peak of Covid-19 on 2020 and 2021, there were only about 3, 4, 5 housekeepers. Two out of this 3 housekeepers stated they were not able to clean all the residents' rooms. One of these 2 housekeepers stated that this housekeeper was also assigned to do the laundry. Therefore, the allegation is substantiated. A finding that a complaint is substantiated means that the allegation is valid because the preponderance of evidence standard is met. Deficiency is cited from Title 22 California Code of Regulations and listed on 9099D. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in civil penalty. Deficiency and plan and proof of correction were discussed with the ED over the phone. ED authorized Ernesto Buendia to sign and receive this report. Exit interview conducted. Appeal Right, LIC9098 Proof of Correction form and copy of this report provided. Page 2 Allegation: Resident (R1) was severely dehydrated. - UNSUBSTANTIATED R1's family member (FM) stated that on 11/04/20, the facility called and told FM that R1 needed to go to the hospital due to the resident not eating for 2 weeks. R1's doctor told FM that R1 was severely dehydrated. The 2 caregivers interviewed stated they give water to residents. One of these caregivers stated giving water to residents 4 to 5 times during their shift. LPA reviewed the documents obtained from the facility and the Plan of Care showed R1 came back from the hospital after being treated for UTI. There was no hospital discharge document or other document indicating R1 was dehydrated. LPA tried to obtain records from FM but unsuccessful. Allegation: Staff did not notify responsible party of resident's (R1) change in health condition. - UNSUBSTANTIATED FM stated that the facility did not inform FM that R1 was not eating and positive of COVID-19. R1's doctor told FM on 11/04/20 that R1 was positive of COVID-19. LPA interviewed 4 staff (2 caregivers and 2 care coordinators) who all stated that when there's a change in resident's health condition, med-tech and facility nurse are informed who in-turn assess the resident. The med-tech or the facility nurse notifies the resident's family member. LPA also reviewed the copy of line list showing the names of residents who were tested positive of COVD-19 from 10/23/20 to 11/20/20 submitted by the facility to the Department of Public Health and provided to Community Care Licensing. R1 was not included on the list. Allegation: Facility did not ensure the COVID-19 positive residents were isolated. Six staff (2 caregivers, 2 housekeepers and 2 care coordinators) were interviewed who all stated that residents who tested positive of COVID-19 were isolated. Two of these staff stated that residents in Memory Care, because of dementia, came out of their rooms to the common area. One of these staff also stated that resident who's not positive of COVID-19 comes out to the common area. ....continued on 9099C (page 3) Allegation: Resident (R1) was missing teeth from dentures. - UNSUBSTANTIATED Six staff (2 caregivers, 2 housekeepers and 2 care coordinators) were interviewed who all stated they never heard or observed any resident missing teeth from dentures. Two of these staff stated that residents dentures may gone were missing but were found in the residents clothing. LPA was not able to interview R1 as R1 had passed away prior to the Department receiving the complaint. Allegation: Resident (R1) missing personal property. UNSUBSTANTIATED FM stated that R1's prescription glasses were missing. Six staff (2 caregivers, 2 housekeepers and 2 care coordinators) were interviewed who all stated they never heard any resident missing eyeglasses. One out of 2 residents interviewed stated not losing anything. The other resident stated not losing eyeglasses. LPA was not able to interview R1 as R1 had passed away prior to the Department receiving the complaint. R1's LIC621 Resident Personal Property And Valuables was reviewed which showed eyeglasses not listed. Based on records review and interviews, the 5 allegations are closed as unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegations may have happened or are valid, there's not a preponderance of evidence to prove that violations occurred. No deficiency cited. The ED authorized Ernesto Buendia to sign and receive this report. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Apr 4, 2025 · control 15-AS-20211008153646

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Apr 18, 2025

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 is not met as evidenced by: -Based on interviews, the licensee did not comply with the section above when the resident's room was not cleaned which posed personal rights risk to person in care.the state’s words, verbatim · CDSS document, Apr 4, 2025

Plan of correction: Executive Director stated she'll in-service the staff. Proof to be submitted by 4/18/25.

Allegation investigated: Facility staff blocks an exit doors presenting a hazard to residents

On 02/21/2025 at 9:00AM, Licensing Program Analyst (LPA) A Gomez arrived unannounced to conduct complaint investigation for the above allegation and deliver findings. LPA was greeting by Care Coordinator, Duncan Agyemang. LPA spoke with Administrator Dolly Rizvi over the phone. During the course of the investigation LPA soke with Administrator over the phone who confirmed that on Febuary 7th 2025 the facility temporarily blocked the fire exits with a bench and other objects so that residents would stop attempting to exit. Administrator states that they were informed that they can not block exits and has since removed the obstacles. LPA observed that every exit is now clear. Report Continues on LIC 9099-C Substantiated Based on LPAs observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Health and Safety Code , 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, Feb 21, 2025 · control 15-AS-20250212141411

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87203 · Plan of correction due date: Feb 21, 2025

All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not met as evidence by: Based on interviews facility staff admits that fire exits were being temporarily blocked to redirect residents which posed a potential safety violation to resident in care.the state’s words, verbatim · CDSS document, Feb 21, 2025

Plan of correction: Facility removed the obstruction POC cleared.

Type of visit: Case Management - Deficiencies

While at the facility for other reason and upon review of roster, Licensing Program Analyst (LPA) Delmundo learned that staff (S1) is not associated to this facility. LPA reviewed S1's file which showed S1 was fingerprinted and cleared, somehow, S1 was disassociated. LPA spoke over the phone with Executive Director (ED) Dolly Rizvi and discussed the above in the presence of Care Coordinator Bessy John. Deficiency is cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of correction by plan of correction due date may result in civil penalty. Deficiency and 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 to Bessy John.the state’s words, verbatim · CDSS document, Dec 6, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87355(e)(2) · Plan of correction due date: Dec 20, 2024

87355 Criminal Record Clearance: (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) -This requirement is not met as evidenced by: -Based on records review and interview, the licensee did not comply with the section above for not having S1 associated which poses a potential safety risk to the persons in care.the state’s words, verbatim · CDSS document, Dec 6, 2024

Plan of correction: Excutive Director stated she'll work on the association of staff. Proof to be submitted by 12/20/24.

Type of visit: Case Management - Incident

At 12:30 pm on this day, December 6, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced in response to the Unusual Incident Report (UIR) received by the Department from the facility on December 5, 2024. LPA met with Wellness Coordinator (WC) Kristinia Morgan and Care Coordinator (CC) Bessy John and informed the reason for visit. UIR indicated that on December 1, 2024, resident (R1) was out with R1's family when R1 was complained of pain in the left wrist. The family took R1 to the hospital where it was discovered that R1's wrist is broken.The UIR is missing last page (page 2) which LPA obtained from CC on this same day. LPA reviewed R1's records and obtained copies of the following documents: Face Sheet; LIC602A Physician's Report; facility notes; hospital's After Visit Summary. LPA conducted interviews. No deficiency cited on this day. WC has to leave the facility and gave permission to have CC sign and receive this report. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Dec 6, 2024

Type of visit: Case Management - Other

On 11/19/24 at 2:35 PM, Licensing Program Analyst (LPA) Greg Clark arrived unannounced to deliver an amended report from the visit that occurred on 10/01/24. LPA met with Administrator, Dolly Rizvi and explained the purpose of the visit. Amended report delivered. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 19, 2024

Type of visit: Required - 1 Year

On 11/18/2024 at 9:15 AM, Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Dolly Rizvi, and explained the purpose of the visit. The facility’s fire clearance was approved for ninety nine (99) non-ambulatory residents, of which nine (9) may be bedridden and approved for eighteen (18) hospice. LPA toured the facility with Wellness Coordinator Kristinia Morgan, including but not limited to residents' apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in visitor bathroom was measured at 110.3 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher all around the facility was last serviced on 10/15/2024. At 10:02 am LPA reviewed 9 residents records. At 10:45 am, LPA reviewed 4 staff records and 4 of 4 were fingerprint cleared and associated to the facility. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 18, 2024

Allegation investigated: Staff is financially abusing resident

On 10/01/244 at 12:30 p.m., Licensing Program Analysts (LPAs) Greg Clark and Ardalan Gharachorlo arrived unannounced to deliver findings in regard to the allegation above. LPA met with Dolly Rizvi, Administrator and explained the purpose of the visit. During the investigation LPAs interviewed S1 and R1 and reviewed R1's file. R1 has lived at the facility for 9 years and is currently in the memory care unit. R1 stated that he did give a staff member money to help her feed her kids but that she never asked R1 for money. R1 further stated that the staff person is no longer allowed to have any contact with him. ***report continues on LIC9099C*** Unsubstantiated ***report continues from LIC9099*** S1 stated that for the protection of the staff involved the staff was reassigned to another section of the facility and that the money R1 gave the staff was a fake $100 bill. This agency has investigated the above complaint. We have found that the complaint was 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. Exit interview conducted, a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 1, 2024 · control 15-AS-20240606163027

Allegation investigated: -Resident (R1) sustained a fractured finger while in care. -Facility staff hit resident (R1).

On this day, September 27, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings on the above allegations. LPA met with Wellness Coordinator (WC) Kristinia Morgan, and informed the reason for visit. LPA also spoke over the phone with Executive Director (ED) Dolly Rizvi. The ED gave permission to WC to sign and receive this report. During the course of investigation, LPA reviewed residents’ records and obtained copies of including but not limited to the following residents’ documents: LIC601 Identification and Emergency Information and Face Sheet; LIC602A Physician's Reports; Pre-placement Appraisal; Appraisal/Needs and Services Plan; Unusual Incident/Injury Reports; hospital discharge document and/or Hospital After Visit Summary. On 11/02/21, 4/08/22 and 8/13/24, LPA interviewed residents (R1, R2, R3, R4, R5) and staff (S1, S2, S3, S4 and S5) and R1’s family member (FM). .....continued on 9099C (page 2) Unsubstantiated Page 2 Allegation: Resident (R1) sustained fractured finger while in care. On 11/02/21, LPA Delmundo interviewed S1, S2, S4, S6, and R1. S2 stated having observed R1 had purplish discoloration at one of the small fingers that on 10/24/21, and that R1 yelled out when it was touched. S2 then had R1 transferred to hospital for evaluation. All other staff interviewed was not able to provide information as to how the injury occurred. S6 stated having observed a fresh wound at R1’s right elbow but had no knowledge of how it happened. S2 and S7 were not aware of the subject incident. S1 reported being aware that the facility’s LVN observed that R1 had swelling on one of R1’s finger. S4 only stated having knowledge that R1 was transferred to hospital due to a swollen finger. R1 reported not remembering how the wound happened and did not state that there was any staff involvement. On 8/13/24, LPA Delmundo interviewed FM, who reported being aware that R1 was sent to hospital for the finger injury; and that R1 can be combative and “out of control” and “could see” R1 causing self-injury due to the behaviors. On 11/2/21, LPA Delmundo reviewed R1’s file and observed the Physician’s report indicating a diagnosis of Dementia with Behavioral Disturbance. Based on all information gathered, the allegation is closed as 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 violations occurred. Allegation: Facility staff hit resident (R1). During complaint intake, the reporting party (RP) stated that R1 informed the RP that R1 is beaten by facility staff. The RP further stated that RP had spoken to FM, who reported being aware that R1 needed transfer to the hospital for an injury. FM further stated that R1 is “manipulative,” “delusional,” and “paranoid”; and did not believe that staff had hurt R1, but that due to aggressive behavior R1 has hurt the staff; and that R1 showed no caution for self-safety. RP stated R1 was sent to hospital via ambulance and diagnosed with right finger fracture. ....continued on 9099C (page 3) Page 3 All 5 staff (S1-S5) interviewed denied hitting residents and stated not observing any staff hitting residents. S4 stated there was an incident when R1 twisted a spoon and scratched S4. S1 confirmed R1 was sent out on 10/2021. S2 stated R1 asked S2 to check R1’s finger and S2 observed discoloration on the left pinkie and R1 was transferred to hospital; however, R1 was discharged back to the facility without the After Visit Summary. Facility’s Internal Incident Report matched S2’s statement. R1 was not able to provide information regarding the subject incident and indicated that staff are “good.” R3 and R4 declined to be interviewed. R2 and R5 stated having no knowledge of or having been aware of staff abusing any resident. Review of R1’s records showed R1 has dementia, aggressive behavior, and behavior disturbance. LPA interviewed R1’s family member (FM) who confirmed RP and staff’s statements that R1 has agitation and behavior issues. FM stated R1 was combative and hurt herself. Based on all information gathered, the allegation is closed as 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 violations occurred. No deficiency cited. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Sep 27, 2024 · control 15-AS-20211026093939

Type of visit: Case Management - Deficiencies

While conducting an investigation of a complaint (Control # 15-AS-20211026093939), resident (R1) showed to Licensing Program Analyst (LPA) Delmundo a wound on R1’s right elbow while LPA was interviewing R1. The wound was about 2 inches x 1 1/2 inches with fresh blood, skin scraped and part of flesh exposed. LPA interviewed the staff (S6) who was assigned to R1 that day. S6 stated she observed R1's wound on the right elbow that day and that the blood was fresh. She attended to other residents and forgot to put bandage on R1's wound nor report to the facility nurse (LVN). S6 further stated does not know what happened and that it could be that R1 hit the bed rails. LPA called LVN who confirmed it was not reported to her. LVN attended to R1 after LPA spoke with her. On this day, September 27, 2024, LPA conducted a case management resulting from the above. LPA met with Wellness Coordinator (WC), and informed the reason for visit. LPA also spoke over the phone with Executive Director (ED) Dolly Rizvi. The ED gave permission to WC to sign and receive this report. Deficiency is cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12-month period may result in civil penalty. Deficiency and plan and proof of correction were discussed with the ED over the phone in the presence of WC. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Sep 27, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Sep 28, 2024

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. -This requirement is not met as evidenced by: -Based on observation and interviews, the licensee did not comply with the section above when staff did not attend to R1 nor call the facility nurse when R1 sustained injury which posed an immediate health, safety and/or personal rights risks to person in care.the state’s words, verbatim · CDSS document, Sep 27, 2024

Plan of correction: Executive Director to in-service the staff and submit copy of training topic with attendees signatures by 9/28/24.

Allegation investigated: Illegal eviction Staff refused to accept resident back from hospital discharge

On 9/18/2024 at 11:00 AM, Licensing Program Analysts (LPAs) K. Nguyen and L. Alexander arrived unannounced to deliver the findings for the above allegations. LPA meet with Executive Director, Dollie Rizvi and explained the purpose of the visit. The allegation refers to R1 received an eviction notice due to R1 conservator no longer want to be responsible for R1 medical, and financial. During the investigation, LPAs interviewed staff and attempted to interviewed resident, but resident was no longer reside at the facility. LPAs reviewed documents of the time frame that facility had issues an eviction noticed to R1. Base of documentations provided by S1. R1 conservator emailed S1 on 5-17-2023 stated that R1 trust fund was no longer available, and R1 conservator is no longer responsible for R1. The fund that R1 have left is enough to pay for the month of June 2023. R1 was sent out to the hospital on July 4, 2023. Facility sent R1 a 30-day eviction noticed on June 1, 2023, and indicated the move out date by July 1, 2023, therefore the allegation is unsubstantiated. Report continued page LIC 9099c… Unsubstantiated During the investigation LPAs interviewed and reviewed documents between S1 and R1 social worker via email exchange. The documents stated S1 did not denial R1 back to the facility after R1 gets discharge, but due to R1 health concerned R1 was sent to a SNIFF after the hospital discharged R1, therefore this allegation is unsubstantiated. 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, Sep 18, 2024 · control 15-AS-20230707150358

Allegation investigated: Staff handled resident roughly

On 09/18/2024 at 11:00 a.m., Licensing Program Analysts (LPAs) L. Alexander and K. Nguyen arrived unannounced to conduct an initial 10-day complaint investigation in regard to the allegation above. LPAs met with Executive Director, Dolly Rizvi and explained the purpose of the visit. During the course of investigation, LPAs L. Alexander and K. Nguyen interviewed residents, resident's family member and staff. LPAs reviewed documents including resident roster, staff roster (LIC 500), staff schedule, physician's reports, Appraisal Needs and Services and incident reports (if applicable) for five (5) residents. LIC9099-C Continued... Unsubstantiated Allegation: Staff handled resident roughly Unsubstantiated. During the course of investigation, LPAs interviewed residents (R), staff (S), and resident family members (W). R1, R2, R3, R4, and R5, stated that they have not witness any staff rough handle any residents at the facility nor heard any of the staff rough handle any residents. S1, S2, S3 and W1 stated they have not witness nor heard any of the facility staff rough handle any residents. All individuals interviewed stated that they have not witnessed any resident's falling, any resident being rough handled or any resident being dropped on the ground. 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. Exit interview conducted, a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 18, 2024 · control 15-AS-20240912122433