The Pavilion at El Dorado Hills

Allegation investigated: Staff do not ensure residents bathing needs were met Staff did no safeguard resident's personal belongings Staff did not ensure that resident received laundry services Residents' sustain injuries due to staff neglect or physical abuse Licensee did not ensure egress doors were properly working Staff do not respond to residents calls in a timely manner Staff did not dispose of resident's trash bin Staff are chemically restraining residents

On 9/10/2026, Licensing Program Analysts (LPAs) Lavinia Muscan and Talwinder Bains arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Administrator Kim Delgado. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: **Report continued on 9099-C** Unsubstantiated Staff did not ensure residents' bathing needs were met. During the investigation, the LPA reviewed facility documentation and conducted interviews with staff regarding residents' bathing needs. The documentation reviewed indicated that staff offered bathing assistance and that the resident refused shower assistance on multiple occasions. Staff documented the resident's refusals. Although staff could have made additional attempts to encourage the resident to accept shower assistance, the evidence obtained established that bathing assistance was offered and the resident's refusals were documented. The investigation did not establish that staff failed to provide the resident with the opportunity to receive bathing assistance. Based on the totality of the evidence obtained, the allegation is UNSUBSTANTIATED. Staff did not safeguard the resident's personal belongings. During the investigation, the LPA conducted interviews and reviewed available facility documentation regarding the resident's personal belongings and valuables. The investigation established that the resident's family reported that items of the resident's clothing were missing. However, the missing clothing items were not documented on the resident's Property and Valuables form. The available documentation did not establish that the specific clothing items reported as missing were present at the facility or were received by the facility for safekeeping. Due to the lack of documentation identifying the missing items on the Property and Valuables form, the investigation was unable to establish that the facility had possession or responsibility for safeguarding the specific items reported missing. Based on the totality of the evidence obtained, there was insufficient evidence to establish by a preponderance of the evidence that staff failed to safeguard the resident's personal belongings. Therefore, the allegation is UNSUBSTANTIATED. Staff did not ensure residents received laundry services. During the investigation, the LPA reviewed available facility documentation and conducted interviews regarding residents' laundry services. The evidence obtained established that laundry services were provided to residents. The investigation also identified reports that multiple items of residents' clothing went missing. As a result, the residents' family began providing laundry services. However, the evidence obtained did not establish that the facility failed to provide laundry services to the residents. Based on the totality of the evidence obtained, the allegation is UNSUBSTANTIATED. Residents sustained injuries due to staff neglect or physical abuse. During the investigation, the LPA conducted interviews and reviewed available facility documentation regarding the alleged injuries. The evidence obtained did not establish a preponderance of evidence demonstrating that residents' injuries were caused by staff neglect or physical abuse. The information obtained through interviews and documentation reviewed did not provide sufficient corroborating evidence to establish that staff intentionally caused injury or that the injuries resulted from staff neglect. Based on the totality of the evidence obtained, the allegation that residents sustained injuries due to staff neglect or physical abuse is UNSUBSTANTIATED. CONTINUE ON PAGE 2 ... PAGE 2 ... Licensee did not ensure egress doors were properly functioning. During the investigation, the LPA reviewed information regarding the facility's egress doors and conducted interviews with facility representatives. The investigation established that the facility experienced issues with its egress doors. However, evidence obtained demonstrated that the facility contacted the appropriate parties to address the identified issues and took action to have the doors repaired. Based on the evidence obtained, the investigation did not establish that the licensee failed to take appropriate action to address the identified egress-door concerns. Therefore, the allegation is UNSUBSTANTIATED. Staff did not respond to residents' calls in a timely manner. During the investigation, the LPA conducted interviews with relevant staff and residents and reviewed available documentation regarding residents' calls for assistance. The evidence obtained did not establish sufficient evidence demonstrating that staff failed to respond to residents' calls in a timely manner. The investigation did not establish a consistent pattern of delayed responses or that staff knowingly failed to respond to residents' requests for assistance. Based on the totality of the evidence obtained, the allegation is UNSUBSTANTIATED. Staff did not dispose of residents' trash. During the investigation, the LPA reviewed information regarding the disposal of residents' trash and conducted observations of the facility. The investigation identified information indicating that residents' trash may not have been removed on some occasions. However, during multiple Department walkthroughs, the LPA observed that trash had been removed from residents' rooms and that residents' rooms were maintained without accumulated trash. Based on the totality of the evidence obtained, the investigation did not establish that staff failed to routinely dispose of residents' trash. Therefore, the allegation is UNSUBSTANTIATED. Staff chemically restrained residents. During the investigation, the LPA reviewed available resident records, medication documentation, and facility records and conducted interviews with relevant individuals regarding the allegation of chemical restraint. The investigation did not identify sufficient evidence to establish that staff administered medication to residents for the purpose of controlling behavior or restricting residents' movement in a manner constituting chemical restraint. Based on the records reviewed and interviews conducted, the preponderance of evidence did not establish that staff chemically restrained residents. Therefore, the allegation is UNSUBSTANTIATED Exit interview conducted. Report left with facility.the state’s words, verbatim · CDSS document, Sep 10, 2026 · control 59-AS-20260527094708

Allegation investigated: Staff did not prevent the spread of scabies.

On 9/10/2026, Licensing Program Analysts (LPAs) Lavinia Muscan and Talwinder Bains arrived at the facility unannounced to deliver complaint findings into the allegation listed above and met with Administrator Kim Delgado. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: Based on observation, record review, and statement reviewed, the facility was following infection control requirements. As a precaution, facility puts out PPE outside the resident room, notifies Public Health, notifies staff of scabies, and an in-service to staff is reviewed on proper handwashing and universal precautions. Facility encouraged residents to stay in their room during the episode. It was observed facility had required PPE outside the resident room; therefore, the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted. Report left with facility. Unfoundedthe state’s words, verbatim · CDSS document, Sep 10, 2026 · control 59-AS-20260819115901

Allegation investigated: Staff did not ensure that resident did not have contact with harmful chemicals.

On August 25, 2026, Licensing Program Analyst (LPA) Lavinia Muscan and Licensing Program Manager (LPM) Laura Munoz arrived at the facility unannounced to open complaint regarding the allegations listed above and met with Health Services Manager Carla Lambert. During investigation, it was learned that staff use Home Defense Insect Killer to address the facility ant problem. The department observed documentation that showed a bottle of the insect killer was left in a resident’s room who as a diagnosis of dementia. Additionally, department staff found multiple ant bait stations in R1’s room accessible to residents in care. Based on documentation, ant bait stations could have toxicity to humans. R1 has a diagnosis of Dementia. Based on the information obtained, the facility did not ensure poisonous chemicals are kept inaccessible to residents in care therefore the allegation is SUBSTANTIATED. Exit interview conducted. Appeal rights and report left with facility. Substantiatedthe state’s words, verbatim · CDSS document, Aug 25, 2026 · control 59-AS-20260819115901

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a)(1) · Plan of correction due date: Aug 26, 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.(1) Disinfectants, cleaning solutions, and poisonous substances shall be stored in areas separate from food supplies as specified in Section 87555, General Food Service Requirements. This was not met as evidenced by ... During investigation, it was learned that staff use Home Defense Insect Killer to address the facility ant problem. The department observed documentation that showed a bottle of the insect killer was left in a resident’s room who as a diagnosis of dementia. Additionally, department staff found multiple ant bait stations in R1’s room accessible to residents in care. Based on documentation, ant bait stations could have toxicity to humans. R1 has a diagnosis of Dementia, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 25, 2026

Plan of correction: HSM agrees to check with maintenance to make sure both HSM and maintenance signs off for apartments treated and chemicals stored and put away. HSM agrees to send in a statement of understanding of this regulation. POC due date 8/26/26.

Allegation investigated: Staff do not ensure residents' bedding is free from ants Staff do not ensure residents' clothing is free from ants Staff do not ensure residents' incontinence briefs are free from ants

On August 25, 2026, Licensing Program Analyst (LPA) Lavinia Muscan and Licensing Program Manager (LPM) Laura Munoz arrived at the facility unannounced to open complaint regarding the allegations listed above and met with HSM Carla Lambert. During the investigation, department staff observed live and dead ants on multiple residents’ bedding and disposable bed pads. Interviews with staff indicated the ant problem as been an ongoing issue. Based on observations, the facility did not ensure residents’ bedding was free of ants therefore the allegation is SUBSTANTIATED. During the investigation, department staff observed live ants crawling on multiple residents’ clothing. Additionally, photos were provided during the course of the investigation that shows ants present on a resident’s brief. It should be noted that the photo of the resident is one of the resident’s beds that were observed with live and dead ants on their bedding. Based on observations, the facility did not ensure residents’ persons free of ants therefore the allegation is SUBSTANTIATED. Exit Interview conducted. Appeal rights and report left with facility. Substantiatedthe state’s words, verbatim · CDSS document, Aug 25, 2026 · control 59-AS-20260818094110

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(3)(c) · Plan of correction due date: Aug 26, 2026

87309 Storage Space and Access (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of:(C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. This was not met as evidenced by ... During the investigation, department staff observed live and dead ants on multiple residents’ bedding and disposable bed pads. Interviews with staff indicated the ant problem as been an ongoing issue, which possess an immediate health and safety hazard to residents in care.the state’s words, verbatim · CDSS document, Aug 25, 2026

Plan of correction: HSM agrees to check each sheet that there are no ants on each shift and clear directions on what to do if there are ants in the room. Clean and disinfect apartment daily. HSM agrees to send in a statement of understanding of this regulation. Also, have pest control come out to do an inspection. POC due date 8/26/26.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Aug 25, 2026

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This was not met as evidenced by ... During the investigation, department staff observed live ants crawling on multiple residents’ clothing. Additionally, photos were provided during the course of the investigation that shows ants present on a resident’s brief. It should be noted that the photo of the resident is one of the resident’s beds that were observed with live and dead ants on their bedding, which poses an immediate health and safety risk to residents in care. .the state’s words, verbatim · CDSS document, Aug 25, 2026

Plan of correction: HSM agrees to check in on residents and train staff to accord safe and comfortable accomodations for residents in care. HSM agrees to send in a statement of understanding of this regulation. POC due date 8/26/26.

Allegation investigated: Neglect led to resident's hospitalization. Staff did not ensure resident's hygiene needs were met while in care. Staff did nof ensure that resident's toileting needs were met while in care. Staff did not address resident's change in condition while in care.

On 8/11/2026, Licensing Program Analysts (LPAs) Lavinia Muscan and Talwinder Bains arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Administrator Kim Delgado. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: **Report continued on 9099-C** Substantiated Facility neglect led to resident hospitalization. Staff did not address resident's change in condition while in care. Based on interviews, record reviews, and other evidence obtained during the investigation, the resident had a documented history of diabetes and required blood glucose monitoring. Facility records reflected a blood glucose level of 290 mg/dL on 2/4/26 (PM), 133 mg/dL on 2/5/26 (AM), 66 mg/dL on 2/6/26 (AM), and a critically low blood glucose level of 44 mg/dL on 2/7/26 at approximately 8:00 a.m. Scheduled PM blood glucose readings on 2/5/26 and 2/6/26 were not documented. The medication technician documented the resident’s blood glucose at 44 mg/dL on 2/7/26 and administered the ordered intervention. However, facility records contained no documentation that the resident’s blood glucose was reassessed following the intervention to determine its effectiveness. Approximately seven hours elapsed without documented follow-up monitoring despite the critically low blood glucose level. At approximately 3:00 p.m. on 2/7/26, the resident was found clammy and unresponsive. The residents’ blood pressure was documented as 55/29, oxygen saturation as 74%, and pulse as 95. Emergency medical services were contacted, and the resident was transported to the hospital, where the resident was diagnosed with a urinary tract infection resulting in sepsis. The investigation determined the facility failed to adequately monitor and reassess the resident following a critically low blood glucose reading and failed to recognize and respond to the resident’s significant change in condition in a timely manner. These failures contributed to the progression of the resident’s deteriorating condition and the need for hospitalization. According to the incident report, R1 was found unresponsive on 02/07/2026 and hospitalized with septic shock due to an E. coli UTI and bacteremia. Staff reported they were unaware of R1's history of UTIs and did not observe a change in condition. Caregivers reported residents were generally checked or changed only two to three times per eight-hour shift due to workload. The Health Services Manager acknowledged R1's known UTI risk factors were not addressed and accepted responsibility, while the Executive Director also acknowledged responsibility and the need for additional staff training. Continue on page 2 ... Facility staff failed to meet the residents’ toileting needs. Based on interviews, record reviews, and other evidence obtained during the investigation, the facility’s Plan of Operation requires incontinent residents to be checked and provided with incontinent care at a minimum of every two hours, including overnight. Staff interviews consistently revealed this expectation was not being met. Multiple staff members stated it was not possible to provide incontinent care every two hours because of staffing limitations and resident need. Staff consistently reported that incontinent residents were generally changed only two to three times during an eight-hour shift rather than every two hours as required by the facility’s own procedures. Documentation reviewed during the investigation did not demonstrate residents consistently received incontinent care at the frequency required by the facility’s Plan of Operation. The investigation further determined staffing practices prevented staff from consistently providing timely toileting assistance and incontinent care. The resident was subsequently hospitalized and diagnosed with a urinary tract infection resulting in sepsis. The Department determined the facility failed to ensure the residents’ toileting and incontinent care needs were consistently met. Facility staff failed to meet the residents’ hygiene needs. Based on interviews, record reviews, and other evidence obtained during the investigation, the facility’s Plan of Operation requires staff to routinely monitor residents and provide hygiene and incontinent care at least every two hours. Interviews conducted during the investigation established staff were unable to consistently comply with this requirement due to staffing limitations. Staff acknowledged residents frequently remained in soiled briefs for extended periods because staff were responsible for more residents than they could appropriately care for during a shift. The investigation determined the facility failed to ensure staff consistently provided hygiene and personal care services necessary to maintain residents in a clean, dry, and comfortable condition as required by the facility’s own policies and applicable regulations. The preponderance of evidence standards has been met. Therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page. Immediate civil penalty of $500.00 was issued today. Failure to correct shall result in civil penalties. Exit interview conducted. Appeal Rights given to administrator. A copy of this report has been provided to facility.the state’s words, verbatim · CDSS document, Aug 11, 2026 · control 59-AS-20260403145712

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Aug 12, 2026

Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met as evidenced by ... Staff did not recognize and respond promptly to resident’s declining condition, including signs and symptoms requiring medical intervention. As a result, the resident’s condition deteriorated and required hospitalization which possess an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 11, 2026

Plan of correction: Administrator will send a letter of understanding of this regulation and will conduct staff training. Facility will submit a plan on how facility will ensure residents change in condition is being monitored. All POC documents are dues by 8/12/26.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87208(a) · Plan of correction due date: Aug 12, 2026

Plan of Operation - The licensee failed to operate the facility in accordance with its approved Plan of Operation. This requirement was not met as evidenced by ... Specifically, the facility’s Plan of Operation required incontinent residents to be checked and provided with incontinent care at least every two hours. Evidence obtained during the investigation demonstrated that residents were not consistently provided care in accordance with the Plan of Operation which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 11, 2026

Plan of correction: Administrator will send a letter of understanding of this regulation and will conduct staff training. Facility will submit a plan on how facility will ensure residents are changed according to the facility Plan of Operation, which is every 2 hours including at night. All POC documents are dues by 8/12/26.

Allegation investigated: Staff blocking door from the outside

On July 6, 2025, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to open complaint into the allegation listed above and met with Administrator Kim Delgado. Upon arrival at the facility, LPA observed a portable door reinforcement bar jamming one of the exterior exit doors of the facility resulting in residents being unable to leave through this door. The ED stated the facility is utilizing the door jammer due to malfunctions of the alarm system. A referral was made to the local fire jurisdiction to determine if the delay egress system is working properly. Based on Department observation facility did not ensure that exit doors were free from obstruction, which poses an immediate health, safety, or personal rights risk to persons in care. The preponderance of evidence standards has been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page. Immediate civil penalty of $500.00 was issued today. Failure to correct shall result in civil penalties. Appeal Rights given to administrator. A copy of this report has been provided to facility. Exit interview conducted. Substantiatedthe state’s words, verbatim · CDSS document, Jul 6, 2026 · control 59-AS-20260706083643

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87307(d)(6) · Plan of correction due date: Jul 7, 2026

87307 Personal Accommodations and Services (d)(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. ... This requirement was not met as evidenced by ... LPA observed a portable door reinforcement bar jamming the exterior exit door of the facility resulting in residents being unable to leave through this door, which poses an immediate health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 6, 2026

Plan of correction: Licensee/Administrator shall ensure all exits are free of obstruction immediately and send a plan to LPA by 7/7/26 on how facility will ensure safety of residents without obstructing any exits.

Allegation investigated: Due to staff neglect, resident sustained pressure injuries

On 4/28/2026, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Administrator Kim Delgado. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: **Report continued on 9099-C** Unsubstantiated Due to staff neglect, resident sustained pressure injuries Review of records and interviews indicates that R1 was receiving ongoing medical oversight from multiple external providers while residing in the facility. R1 was on home health services that visited the facility three times per week to provide skilled nursing care, including wound management. In addition, R1 received consistent wound care services through InnovAge on Fridays, where the wound was being actively monitored and treated by licensed nursing staff. Documentation indicates R1’s care needs were being addressed through coordinated medical services outside the facility staff. R1 was later admitted on hospice care after being enrolled through home health services beginning 02/20/2026. Based on the information obtained, there is insufficient evidence to demonstrate that facility staff did not provide care and supervision in accordance with Title 22, or that any action or inaction by facility staff directly resulted in or contributed to the development or worsening of R1’s injuries. Therefore, the allegation is determined to be UNSUBSTANTIATED. Exit interview conducted. Report left with facility.the state’s words, verbatim · CDSS document, Apr 28, 2026 · control 59-AS-20260310163302

Allegation investigated: Residents sustained injuries due to staff neglect Staff did not prevent the spread of scabies Staff are not following infection control requirements Staff did not notify residents authorized representatives of incidents Staff did not ensure they had PPE

On February 23, 2026, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Administrator Kim Delgado. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: **Report continued on 9099-C** Unfounded Residents sustained injuries due to staff neglect The department conducted interviews, facility observation and record review to investigate the above allegation. During interviews with facility staff, it has been discovered that facility provided appropriate care to the residents based on resident’s documented needs and service plans. Six (6) staff interviews revealed that they were not aware of any injuries of any residents in care that were due to staff neglect; therefore, the above allegation is found to be UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Staff did not notify residents authorized representatives of incidents The department conducted interviews and reviewed records concerning the allegation above. Through six (6) staff interviews it was determined that staff do contact responsible parties (RP) regarding all incidents such as falls, med errors, etc. Based on information gathered, the department finds the allegations to be UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Staff did not ensure they had PPE Staff did not prevent the spread of scabies Staff are not following infection control requirements Based on observation, record review, and statement reviewed, the facility was following infection control requirements. As a precaution, during the first sign of a rash, facility puts out PPE outside the resident room, notifies staff of the potential of scabies, and an in-service to staff is reviewed on proper handwashing and universal precautions. Facility encouraged residents to stay in their room during the episode. It was observed facility had required PPE outside the resident room; therefore, the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted. Report left with facility.the state’s words, verbatim · CDSS document, Feb 23, 2026 · control 59-AS-20251125150454

Type of visit: Case Management - Incident

On 11/24/2025, Licensing Program Analysts (LPAs) Lavinia Muscan and Talwinder Bains arrived at the facility unannounced to conduct a case management visit and met with Administrator Kim Delgado. Department followed up on an incident report sent by facility on 11/21/25 regarding 3 suspected cases of scabies for residents. Per staff, it was learned that only one case was confirmed and the other two residents were treated by their physician's as a preventative measure. Staff also indicated that one staff is out dues to suspected scabies, but it is not confirmed. Facility did not report any other concerns for other residents or staff during this visit. Facility will reach out to local public health for any advise regarding this matter. Facility will keep department updated. No deficiencies were cited during this visit. Department will follow up further if warranted. Exit interview conducted. Copy of report left with Administrator.the state’s words, verbatim · CDSS document, Nov 24, 2025

Type of visit: Prelicensing

On November 3, 2025, Licensing Program Analyst (LPA) Lavinia Muscan met with Administrator, Kim Delgado, to conduct a Pre- Licensing visit. Administrator holds a current administrator certificate (#7003011740 with expiration date 10/31/2027). LPA toured the facility with Staff. LPA toured resident bedrooms and observed that they were properly furnished and maintained. LPA toured common bathrooms and observed the bathrooms to be clean and sanitary. LPA toured kitchen, common areas, and outside areas. Smoke detectors are operational. There are carbon monoxide detectors which are functioning. The Fire extinguisher was charged, serviced and functional. All exits were unobstructed. All toxins, medications, and sharps were locked and stored away. Component III was waived as the current administrator is an administrator for an RCFE Facility licensed by CCLD . LPA will forward findings to the Centralized Application Bureau (CAB) that facility met all the pre-licensing components. Applicant has satisfied all requirements in accordance to Title 22, California Code of Regulations on today's pre-licensing inspection. A copy of this report was provided to the facility. Exit interview conducted.the state’s words, verbatim · CDSS document, Nov 3, 2025

Type of visit: Office

Component II completion: Successful Facility Type: Residential Care Facility for the Elderly (RCFE) Application Type: Change in Ownership (CHOW) Capacity: 64 Census (if any clients in care):60 COMP II Participants: Douglas Sproul, Applicant Kimberly Delgado, Administrator Interview Method:Virtual interview (Microsoft Teams) On October 22, 2025, Applicant and Administrator participated in COMP II. Identification of the Applicant and Administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, Applicant and Administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant and Administrator’s understanding of following areas: 1. Facility Operation: License Type, Client/Resident Populations, and Program. 2. Admission Policies 3. Staffing Requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General Provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing Readinessthe state’s words, verbatim · CDSS document, Oct 22, 2025