The Point at Rockridge

Type of visit: Annual/Random

On 08/31/2026 at 02:30 AM, Licensing Program Analysts (LPA) David Doidge arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Memory Care Director Nazmeen Begum and explained the purpose of the visit. LPA toured the facility including but not limited to residents’ apartments, bathrooms, multiple activity rooms, kitchen, and common areas. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 75 degrees Fahrenheit. The hot water temperature in a shared bathroom was measured at 114.6 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 chemicals are locked and inaccessible to residents in care. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 06/09/2026. Emergency Disaster Plan was last posted on 02/24/2026. First aid kit was observed to be complete. Fire and emergency disaster drills are conducted monthly. The last fire was conducted on 08/20/2026, LPAs reviewed five (5) residents records and five (5) staff records, all were complete. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 31, 2026

Allegation investigated: Staff did not seek emergency care services for resident in a timely manner

On 05/29/2026 at 11:00 AM, Licensing Program Analyst (LPA) David Doidge arrived unannounced to deliver findings in regards to the allegation above. LPA met with Executive Director Anna Reddy and explained the purpose of the visit. During the investigation, LPA collected the following documents: Resident Roster, Staff Roster, List of staff that have left since November, Physician Report (LIC602), Appraisal Needs and Services, and the Identification and Emergency Information form for four (4) residents. The Department also obtained a Death Certificate, Coroner’s Report, and a Police Report for R1. The Department interviewed S1, S2, S3, S4, S5, S6, S7, S8, R2, and R3. Allegation: Staff did not seek emergency care services for resident in a timely manner Continued on LIC9099-C Substantiated Continued from LIC9099 Investigation Findings: It was reported to the department that staff waited approximately 60 minutes prior to calling 911. S3 stated S3 noticed at 8:30 AM that the bathroom door where R1 was found was locked. S3 returned at 9:30 AM to open and clean the bathroom when S3 found R1 unresponsive and yelled for someone to call 911. S8 stated S3 informed S8 about 9:50 AM that S3 found R1 unresponsive and to call 911. S6 reported hearing S3 call for someone to call for 911 and did so at 8:30 AM. According to the Oakland Fire Department (FD) Incident Report, the FD wasn’t notified of R1’s need for emergency services until approximately 10:21 AM. When asked by the FD why facility staff waited 60 minutes before calling 911, the Med Tech on duty was unable to explain, therefore the allegation is SUBSTANTIATED. Based interviews conducted during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. Deficiency is cited from Title 22 California Code of Regulations (see LIC9099D). Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in an additional civil penalty. Deficiency and plan and proof of correction were discussed with Executive Director Anna Reddy. Exit interview conducted, Appeal Rights, and a copy this report provided. Continued from LIC9099 Investigation Findings: It was reported to the department that Neglect and Lack of Care by staff resulted in the death of resident. According to the Death Certificate, R1’s immediate cause of death was due to cardiopulmonary arrest, onset interval of minutes and coronary artery disease, onset interval of years. According to the coroner’s report, R1’s manner of death was natural, stemming from cardiopulmonary arrest and coronary artery disease. The coroner’s office reported that providing or seeking medical attention sooner would not have made a difference in the cause of R1’s death While it is believed that facility staff failed to perform, and/or properly perform CPR on R1 upon finding R1 unresponsive and non-breathing, there is no indication this resulted in R1’s death. Based on the Death Certificate findings, the allegation is UNSUBSTANTIATED. Allegation: Staff engaged in the misuse of the emergency 9-1-1 system Investigation Findings: It was reported to the department that the facility staff have judiciously used the 911 system for a wide array of calls, including running out of art supplies, residents being thirsty, or the inability of the residents to get in touch with staff for a simple aspirin, thus calling 911 for assistance. Normally, 911 crew are met with a shrug of the shoulder from staff during these calls. These types of calls can be categorized as an annoyance and/or abuse of the 911 system. LPA interviewed O1 on the phone, who stated that EMT will come out to the facility for calls that are determined, upon arrival, to be non-emergency and will vary from things like someone fell and no one wanted to lift the person, to simple things that a person acting as a “Good Samaritan” could assist someone with. LPA asked what was meant by “Good Samaritan”, O1 answered that a person acting in good faith to assist someone cannot not punished legally if there are adverse outcomes. O1 feels staff in the facility should act in that nature rather than calling 911 for “every little thing.”. S1 informed LPA staff are taught to call 911 every fall and for any situation they deem an emergency. S1 also informed LPA that staff are usually not informed when a resident calls 911 on his or her own nor does they facility request that residents inform staff before calling 911. S2 confirmed that staff in the facility are not clinically trained and would rather that staff err on the side of caution and call than to assist and further harm a resident in need, as S2 confirmed staff are trained to do. S3 greets individuals coming into the facility. S3 does not ask 911 responders for the reason they are coming in. S3 is usually aware that 911 was called, unless it was a resident. Continued on LIC9099-C Continued from LIC9099-C S4 is aware that at times residents have called 911 without staff being informed, but S4 has been instructed to not stop a resident from calling 911. S5 and S6 assist residents in the activities room. S5 and S6 say paramedics have never needed to stop a class to assist residents. S3, S4, S5 and S5 all told LPA that 911 is called, per facility policy, every time there is a fall and overtime the resident requiring assistance is deemed to need assistance beyond the scope of training that staff member has. R1, R2 and R3 all stated they had never called 911 on their own. R1, R2 and R3 all feel that staff and residents should be able to call 911 without seeking approval first. Based on interviews the above allegation is UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. No deficiencies were cited during this inspection. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, May 29, 2026 · control 15-AS-20260128140045

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Jun 12, 2026

The licensee shall immediately telephone 9-1-1 …an imminent threat to a resident’s health…apparent life-threatening medical crisis... This requirement was not met as evidence by: Based on interviews and file review, the licensee did not comply with the section cited above by staff not immediately calling 911 when a resident was in need of emergency care which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, May 29, 2026

Plan of correction: By POC date, Licensee will do an in service training to all staff on the regulation regarding calling 911, and submit a to the facility and submit proof of training to LPA.

Allegation investigated: Staff did not prevent resident from wandering from the facility

On 05/29/2026 at 10:45 AM, Licensing Program Analyst (LPA) David Doidge arrived unannounced to conduct an initial 10-day complaint investigation and to deliver findings regarding the allegation above. LPA met with Executive Director Anna Reddy and explained the purpose of the visit. During the course of the investigation, LPAs obtained copies of the Physician’s Reports, Appraisals Needs and Services for one resident. LPAs also interviewed S1, S2 and R1. Allegation: Staff did not prevent resident from wandering from the facility Investigation Findings: It was reported to the department that around 5 PM on Mat 22nd, staff could not find a R1 in the facility. R1 is in the memory care unit and cannot leave the facility unassisted, as verified by R1’s Physician’s report. Continued on LIC9099-C Substantiated Continued from LIC9099 S1 informed LPA that S1 was not in the facility at the time of the elopement and referred LPA to S2 for more information. S2 stated that S2’s had already gone home for the day when staff called to inform S2 of the elopement of R1. 911 was called before S2 returned to the facility, and S2 notified the responsible parties upon return to the facility. R1 had been given a tracking device by R1’s family members, as confirmed by R1’s responsible party, and the family used the device to locate R1 and direct the police to R1’s location. R1 was returned to the facility and evaluated by staff and later a physician with no health or physical issues. S2 informed LPA that a staff member was in the memory care unit delivering food and held the door open for R1 thinking that R1 was not a memory care resident. R1 proceeded down the elevator and walked out the front door. S2 reviewed security cameras and saw that at the time of R1 elopement, a group of visitors had all walked out together, making it difficult for the concierge to see R1. S2 informed LPA that food prep staff had been given key fobs to access the memory care unit to ease the delivering of meals. The food staff member was not familiar with any of the memory care residents and simply mistook the resident for a visitor. Based on interviews conducted the above allegation is SUBSTANTIATED. 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. Deficiency is cited from Title 22 California Code of Regulations (see LIC9099D). Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in an additional civil penalty. Deficiency and plan and proof of correction were discussed with Executive Director Anna Reddy Exit interview conducted, Appeal Rights, and a copy this report provided.the state’s words, verbatim · CDSS document, May 29, 2026 · control 15-AS-20260526173431

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: May 29, 2026

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 evidence by: Based on record review and interviews, licensee did not comply with the section cited above by having resident leave the facility unassisted which poses a potential health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, May 29, 2026

Plan of correction: The facility has already address this issue and made changes to help prevent further elopements. Memory Care director has taken the key fobs away from non memory care staff and given an in-service training to all staff

Allegation investigated: Staff are financially abusing resident Staff did not safeguard resident's belongings Staff did not report incident to appropriate parties

On 4/30/26 at 12 pm, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to delivered finding for the above allegations. LPA meet with Administrator Anna Reddy and explained the reason for the visit. It was alleged that staff financially abused the residents - unsubstantiated. During the course of investigation LPA conducted interviews with eight (8) staff and six (6) residents, as well as a review of records including but not limited to R1’s admission agreement, resident service documents, personal assistance care plan, additional items and services, services by outside providers, one-on-one care, dementia care provisions, terms and obligations, fee change documentation, service plan, level of care transfer documents, resident rights, and resident charges/payment ledger dated 10/31/2024 to present. Report continued on LIC 9099c… Unsubstantiated Report continued… Further review of the residents’ financial records, including the payment ledger, showed that R1 was responsible for issuing payments to the facility. Documentation confirmed that multiple checks were issued by R1 for rent and associated charges, including: $9,000 on 01/13/2025, $1,045 on 01/20/2025, $13,788.68 on 01/30/2025, and $5,150 on 02/20/2025, totaling $28,983.68. These charges were consistent with rent, late fees, and previously returned checks. Additionally, the Administrator (ADM) reported that during R1’s hospitalization, R1’s checkbook was not in the facility's possession. Upon R1’s return, a friend assisted R1 with managing their checkbook due to outstanding rent payments. There was no evidence obtained through interviews or document review indicating that staff had access to, control over, or misuse of R1’s financial resources. It was alleged that the facility failed to safeguard the resident’s belongings- unsubstantiated Record review indicated that at the time of admission on 10/18/2024, R1 declined to complete the Resident Personal Property and Valuables form (LIC 621), opting out of documenting personal belongings with the facility. Therefore, the facility did not assume responsibility for safeguarding undocumented personal property. Report Continued on LIC 9099c1... Report Continued LIC 9099c1... Interviews with staff and residents did not reveal any concerns or observations supporting allegations of financial abuse or of facility staff mishandling personal belongings. It was alleged that the staff did not report the incident to the appropriate parties- unsubstantiated During the investigation, LPA conducted interviews with R1 and R1F. Record review revealed that at the time of admission and during the period in question, Resident 1 (R1) did not have a designated Power of Attorney (POA), a responsible party, or family members involved in their care. Therefore, no facility representatives were identified to notify them of the incident. Further information obtained indicated that a POA was only recently established to oversee R1’s healthcare decisions. There was no evidence that the facility failed to notify any appropriate or legally authorized parties at the time of the incident. Although the allegations may have occurred or be valid, there is not a preponderance of evidence to prove whether the alleged violation did or did not occur; the allegations is UNSUBSTANTIATED. An exit interview is conducted, and a copy of this report is provided.the state’s words, verbatim · CDSS document, Apr 30, 2026 · control 15-AS-20260220154303

Type of visit: Case Management - Other

On 04/29/2026 at 12:45 PM, Licensing Program Analyst (LPA) David Doidge arrived unannounced to deliver and amendment to a complaint dated 02/13/2026. findings. LPA met with Director of Health and Wellness Robert Aurthur and explained the purpose of the visit. During the visit. LPA interviewed five (5) residents. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 29, 2026

Allegation investigated: Staff are charging extra fees to the resident in care without providing a clear explanation

On 04/03/2026 at 12:00 PM, Licensing Program Analyst (LPA) David Doidge arrived unannounced to conduct an initial 10-day complaint investigation and to deliver findings regarding the allegation above. LPA met with Business Office Director Pedro Uribe and explained the purpose of the visit. During the course of the investigation, LPA obtained copies of correspondence between the facility and R1 and responsible party. LPA interviewed S1. LPA was also contacted by the responsible party. Allegations: Staff are charging extra fees to the resident in care without providing a clear explanation Continued on LIC9099-C Unsubstantiated Continued from LIC9099 Investigation Findings: It was reported to the department that the facility is threatening to evict a resident, claiming that the account is seriously past due. RP reported receiving a notice saying if no payment was made in full by the end of the week the facility would "escalate" including taking steps to evict. RP informed LPA that there is a past due amount on R1’s account and that the facility was not providing any documentation showing how the past due amount was totaled or assessed. LPA interviewed S1 in the facility who provided LPA R1’s payment Ledger as well as correspondence between the facility and R1’s responsible party. S1 showed LPA how R1 is billed based on R1’s assessments. While interviewing S1, RP called LPA to inform LPA that the facility had in fact sent all the documentation to RP, noting it was a communication error on the part of the RP. RP confirmed receipt of correspondence noting it had gone into a “spam folder” by RP’s mistake. LPA confirmed with S1 and reviewed email correspondence that show emails were sent and the communication between the facility and the RP has been resolved. LPA also reviewed R1’s payment ledger to confirm R1’s account is in good standing. Based on interviews and record reviews conducted, the above allegation is unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. No deficiencies cited during the visit. Exit interview conducted and a copy this report was provided.the state’s words, verbatim · CDSS document, Apr 3, 2026 · control 15-AS-20260327142312

Allegation investigated: Staff did not safeguard resident’s personal belongings

On 02/13/2026 at 10:30 AM, Licensing Program Analyst (LPA) David Doidge arrived unannounced to conduct an initial 10-day complaint investigation and to deliver findings in regards to the allegation above. LPA met with Executive Director Anna Reddy and explained the purpose of the visit. During the course of the investigation, LPA obtained copies of R1’s Physician’s Report, Appraisal Needs and Services Plan, Admission Agreement, Identification and Emergency sheet, Resident Theft and Loss Record for two incidents, and correspondence between the facility and R1’s Responsible Party. LPA interviewed R1,and 6 staff members. Allegations: Staff did not safeguard resident’s personal belongings Continued on LIC9099-C Unsubstantiated Continued from LIC9099 Investigation Findings: It was reported to the department that on two separate occasions money was taken from a resident’s purse along with a debit card. Each room in Assisted Living has a room safe, and residents are encouraged to keep their room doors locked and valuables out away. The facility did complete a Theft and Loss Record for both incidents and notify the responsible party of both incidents. The Theft and Loss Records show that Oakland Police Department was notified for the lost credit card, but not for the missing cash. R1 stated there was one hundred dollars in R1’s purse in R1’s room, given to R1 by R1’s daughter. About a week after being given the cash, it went missing. R1 feels it was taken from R1’s room while R1 was out of R1’s room. S1 spoke with R1 about the missing cash and created a Theft and Loss Record. S1 and S3 stated that R1 is forgetful and has forgotten R1’s purse in varies places throughout the facility as well as other items. S3 told LPA that R1 will repeat stories and thoughts when talking to S3, and has often times forgotten to clean up or feed R1’s cats. S1 and S3 have voiced concerns over R1’s memory. S2, S3, and S4 reported not knowing of the incident. Neither S2, S3, nor S4 reported ever taking money from a resident, nor suspecting other coworkers of such. In record review, R1 does have Mild Cognitive Impairment and a diagnosis of Bipolar. LPA did observe R1 having difficulty remembering the order of events, and lapse in recall of when the incidents occurred. Based on interviews, the allegation is UNSUBSTANTIATED, Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies cited during the visit. Exit interview conducted and a copy this report was provided.the state’s words, verbatim · CDSS document, Feb 13, 2026 · control 15-AS-20260204102043

Allegation investigated: Staff did not safeguard resident’s personal belongings

On 02/13/2026 at 10:30 AM, Licensing Program Analyst (LPA) David Doidge arrived unannounced to conduct an initial 10-day complaint investigation and to deliver findings in regards to the allegation above. LPA met with Executive Director Anna Reddy and explained the purpose of the visit. During the course of the investigation, LPA obtained copies of R1’s Physician’s Report, Appraisal Needs and Services Plan, Admission Agreement, Identification and Emergency sheet, Resident Theft and Loss Record for two incidents, and correspondence between the facility and R1’s Responsible Party. LPA interviewed R1,and 6 staff members. Allegations: Staff did not safeguard resident’s personal belongings Continued on LIC9099-C Unsubstantiated Continued from LIC9099 Investigation Findings: It was reported to the department that on two separate occasions money was taken from a resident’s purse along with a debit card. Each room in Assisted Living has a room safe, and residents are encouraged to keep their room doors locked and valuables out away. The facility did complete a Theft and Loss Record for both incidents and notify the responsible party of both incidents. The Theft and Loss Records show that Oakland Police Department was notified for the lost credit card, but not for the missing cash. R1 stated there was one hundred dollars in R1’s purse in R1’s room, given to R1 by R1’s daughter. About a week after being given the cash, it went missing. R1 feels it was taken from R1’s room while R1 was out of R1’s room. S1 spoke with R1 about the missing cash and created a Theft and Loss Record. S1 and S3 stated that R1 is forgetful and has forgotten R1’s purse in varies places throughout the facility as well as other items. S3 told LPA that R1 will repeat stories and thoughts when talking to S3, and has often times forgotten to clean up or feed R1’s cats. S1 and S3 have voiced concerns over R1’s memory. S2, S3, and S4 reported not knowing of the incident. Neither S2, S3, nor S4 reported ever taking money from a resident, nor suspecting other coworkers of such. In record review, R1 does have Mild Cognitive Impairment and a diagnosis of Bipolar. LPA did observe R1 having difficulty remembering the order of events, and lapse in recall of when the incidents occurred. Based on interviews, the allegation is UNSUBSTANTIATED, Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies cited during the visit. Exit interview conducted and a copy this report was provided.the state’s words, verbatim · CDSS document, Feb 13, 2026 · control 15-AS-20260204102043

Type of visit: Case Management - Health Checks

On 02/03/2026 at 01:30 PM, Licensing Program Analyst (LPA) David Doidge arrived unannounced to conduct a health and safety check. LPA met with Executive Director Anna Reddy and explained the purpose of the visit. LPA toured the facility including but not limited to bedrooms, bathrooms, common area, kitchen, and outdoor area. There was sufficient supply of perishable and nonperishable foods. Multiple fire extinguishers were observed; last serviced on 07/10/2025. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Feb 3, 2026

Allegation investigated: Facility elevator is in disrepair Staff do not ensure residents are provided supervision Administration qualifications

On 12/19/2025 at 11:30 AM, Licensing Program Analyst (LPA) David Doidge arrived unannounced to conduct an initial 10-day complaint investigation and to deliver findings in regards to the allegations above. LPA met with Executive Director (ED) Anna Reddy and explained the purpose of the visit. During the course of the investigation, LPA obtained copy of a Physician’s Report and Level of Care Appraisal for 1 resident, and records of the facility’s elevator scheduled maintenance. Allegations: Facility elevator is in disrepair. Investigation Findings: It was reported to the department that the facility’s elevator has been out for a week. LPA rode both elevators and observed both to be in working condition. Continued on LIC9099-C Unsubstantiated Continued from LIC9099 While riding the elevators, LPA spoke with multiple staff and residents also riding the elevators who all confirmed neither elevator had been down for longer than a few hours for service. ED provided the elevators scheduled maintenance records showing that on 11/21/2025 passenger elevator 2 got stuck between floors with no one on board. A technician arrived at 9:23 AM and by 1:08 PM left with the elevator back in service. Records show at no point either elevator being out of service for longer than a few hours. Based on the information obtained and observation, this allegation is unsubstantiated. Allegations: Staff do not ensure residents are provided supervision Investigation Findings: It was reported to the department that a resident will spend hours outside picking up leaves and no staff member or person ever goes out to help that resident. During the investigation, LPA walked around in front of the facility and encountered R1 getting ready to pick up leaves. R1 informed LPA that R1 enjoys cleaning up leaves as it provides exercise and fresh air, R1 checks the weather, dresses appropriately for comfort and mobility, and has the sense to not go out when it is raining. R1 was lucid, oriented and showed no signs of dementia or cognitive impairment. R1 is independent and prefers independent activities to social activities. LPA spoke with ED who confirmed R1 is checked on by staff and is not fond of social activities in the facility. A review of R1’s physicians Report shows R1 may leave independently with no escort and has no cognitive impairment. Based on the information obtained, observation and interviews, this allegation is unsubstantiated. Allegations: Administration qualifications Investigation Findings: It was reported to the department that the administrator quit. LPA spoke with the administrator, ED, and verified the ED had not quit. Based on observation and interview, this allegation is unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted, a copy of this report provided.the state’s words, verbatim · CDSS document, Dec 19, 2025 · control 15-AS-20251216165342

Allegation investigated: Licensee is not providing resident's records to their responsible party as required.

On 12/09/2025 at 3:35 PM, Licensing Program Analyst (LPA) David Doidge arrived unannounced to conduct close a complaint and deliver findings in regards to the allegation above. LPA met with Executive Director Anna Reddy and explained the reason for the visit. During the course of the investigation, LPA obtained and reviewed a copy of the request from the responsible party’s attorney seeking all documentation pertaining to the resident. Allegation: Licensee is not providing resident's records to their party responsible as required. Investigation Findings: It was reported to the department that the facility had yet to provide requested records to the responsible party’s attorney. The responsible party does have authorization to request a copy of the documents pertaining to the residents, however, the letter requesting the documentation os not from the responsible party. Continued on LIC9099-C Unsubstantiated Continued from LIC9099 The request comes from the responsible party’s attorney who does not have standing to request those documents, therefore this allegation is unsubstantiated. The facility has since provide all requested documents. 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, Dec 9, 2025 · control 15-AS-20251009133133

Allegation investigated: Staff are not responding to resident's call button in a timely manner Staff are not providing adequate food service for resident Staff did not ensure the elevator was not in disrepair

On 11/04/2025 at 10:05 AM, Licensing Program Analysts (LPAs) L. Alexander and K. Nguyen conducted a subsequent visit and met with Executive Director (ED), Anna Reddy, to deliver findings for the above allegations. LPAs explained the purpose of the visit to the ED. Allegation: Staff are not responding to resident's call button in a timely manner Finding: Unsubstantiated On 12/07/2024, Licensing Program Analyst (LPA) L. Alexander interviewed Witness (W1). W1 stated that on 12/03/2024, Resident (R1) called around 2:00 a.m. and reported that they had fallen and were pressing their call button but received no response. W1 stated that R1 reported remaining on the ground for approximately one hour before staff arrived. W1 also stated that R1 fell again on 12/05/2024. LIC9099-C Continued... Unsubstantiated LIC9099-C (Page 2) On 12/11/2024, LPA interviewed Residents (R2 and R3). Both residents stated that it can take up to 30 minutes for staff to respond to their call lights. LPA reviewed the facility’s call pendant report for December 2024, which showed no record of R1 activating their call pendant on 12/03/2024, 12/05/2024, or at any time during the month. The report also indicated an average response time of approximately 20 minutes. Allegation: Staff are not providing adequate food service for residents Finding: Unsubstantiated On 12/07/2024, LPA Alexander interviewed W1, who stated that on 11/26/2024, the dining room was messy around 12:30 p.m. W1 reported that the facility provides a menu to order from, but the food tastes as if it came out of a plastic bag. W1 further stated that the facility has served hot dogs in cold buns with potato chips and that the food quality is not reflective of what residents pay for. W1 also stated that a pasta dish was once served cold and expressed concern that R1 was not drinking enough water. On 12/11/2024, LPA interviewed Residents (R2 and R3), who stated that the food is sometimes cold and not always good. R3 further stated that the facility provides an “Anytime Menu” offering six entrees and five salads, which residents enjoy. LPA interviewed Staff (S2), who stated that the kitchen offers a variety of dishes daily and that residents can also order from the alternative menu. LIC9099-C Continued... LIC9099-C (Page 3) LPA reviewed the facility menu dated 10/28/2024 through 12/15/2024, which shows three meals per day with varying options. During observation of lunch and dinner service, LPA observed dining staff clearing dishes promptly and cleaning tables. Residents R4–R7 were also interviewed and reported that their meals were good and generally served on time according to the posted menu. Allegation: Staff did not ensure the elevator was not in disrepair Finding: Unsubstantiated On 12/07/2024, LPA Alexander interviewed W1, who stated that only one of the facility’s two elevators was working and that it was reported repairs could take approximately two months. On 12/11/2024, LPA interviewed Staff (S1), who confirmed that elevator #2 was not operational and that a service call had been placed with KONE for repair. S1 stated that the elevator would remain out of service pending the delivery of necessary parts. LPA reviewed a KONE service order dated 12/04/2024, which indicated the installation of a new elevator drive system for elevator #2. The report stated that the existing drive had failed and was obsolete, requiring engineering and manufacturing of a compatible replacement. Due to this, the repair process was expected to take several weeks to months. Although the allegations may have occurred or may be valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur. Therefore, all allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 4, 2025 · control 15-AS-20241205135615

Type of visit: Required - 1 Year

On 07/16/2025 at 11:00 AM, Licensing Program Analyst (LPA) David Doidge arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director Anna Reddy and explained the purpose of the visit. LPA toured the facility including but not limited to residents’ apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 76 degrees Fahrenheit. The hot water temperature in a shared bathroom was measured at 120 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 toxics are locked and inaccessible to residents in care. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguishers were last serviced on 07/10/2025. Emergency Disaster Plan was last posted on 07/16/2025. First aid kit was observed to be complete. Emergency disaster drills conducted monthly, last on 07/02/2025. LPA reviewed five (5) residents records and five (5) staff records; all were complete. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 16, 2025

Allegation investigated: Staff hurt resident Staff do not clean the facility properly

On 2/13/2025 at 3:05PM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to delivery finding to the complaint investigation in regard to the allegations above. LPA met with Executive Director, Anna Reddy and informed her the reason for visit. Report Continued on LIC 9099c… Unsubstantiated Allegation: Staff hurt resident. Unsubstantiated During the course of investigation LPA interviewed 3 residents (R) that are in care of S3. LPA interviewed 3 staff (S) that are on the same shift as S3, and one Witness (W). R1 stated that S3 assisted R1 well. R1 stated “There have not been any time that I felt that a staff hurt me. Staff and myself get along and I do get my needs meet. No staff hurt me. Staff don’t do anything intentional that hurt me. Staff treat me well”. LPA reviewed documents that facility provided related to the above allegation. Facility follow protocol and put S3 on leave while conducting the investigation. Facility concluded that S3 did not hurt R1 intentional. LPA conducted interview 3 staff that worked the same shift as S3. 3 out of 3 stated they have not witnessed nor heard S3 hurt any residents. LPA conducted interviewed with W. W stated S3 “she didn’t not hurt resident intentional, and resident was speaking to low”. Allegation: Staff do not clean the facility properly. Unsubstantiated During the investigation LPA interviewed 2 housekeeping staff, and review housekeeping daily schedule, and housekeeping cleaning check list. LPA toured the facility including but not limited to 6 residents’ apartments, bathrooms, multiple activity rooms, kitchen, common areas and courtyard. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. This agency has investigated the complaint alleging staff hurt resident, and staff do not clean the facility properly. 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, Feb 13, 2025 · control 15-AS-20250203123159

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct a case management due to a complaint visit. LPA request facility to conduct an in-service training for all care staff including but not limited to ADL and resident personal rights submitted to CCLD by 2/21/25 including all care staff signature attending the training. No deficiency issue today. Exit interview is conducted and a copy of this report is provided.the state’s words, verbatim · CDSS document, Feb 13, 2025

Type of visit: Collateral

On 1/15/2025 at approximately 4:15 PM, Licensing Program Analyst (LPA) James Sampair arrived unannounced at the facility for this collateral visit to have an Amended copy of the LIC 9099 and LIC 9099-C from Complaint 15-AS-20241106155241 signed by a member of the management team. Upon entry into the facility, the LPA stated the purpose of the visit to Executive Director (ED) Becca Black. The LPA reviewed the LIC 9099 and LIC 9099-C with the ED, after which the ED signed the amended documents. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 15, 2025

Allegation investigated: Staff are sleeping during the evening shifts

On 12/26/2023 at 12:30 p.m., Licensing Program Analysts (LPAs) Greg Clark and David Doidge arrived unannounced to conduct an initial 10-day complaint investigation and deliver findings in regard to the allegation above. LPAs met with Ebony Foy Generations Program Director and explained the purpose of the visit. During the course of the investigation LPAs attempted to reach W1, but was unsuccessful. LPAs did interview facility staff (S1, S2, S3, S4 and S5). LPAs interviewed S1 who stated staff in memory care unit take their breaks in the dinning area of memory care and may occationally close their eyes and rest. S1 further stated that staff are required to clock in and out for breaks. Most staff will use alarms on their phone to time breaks. ***report continues on LIC9099C*** Unsubstantiated ***report continues from LIC9099*** LPAs interviewed S2, who also stated staff in the memory care unit will take breaks in the dinning area. S3, S4 and S5 all stated that NOC staff sometimes take breaks in the dining room area and may close their eyes to get some rest. All staff stated that they have never seen NOC staff sleeping while on duty. This agency has investigated the complaint alleging staff are sleeping during the evening shifts. 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, Dec 26, 2024 · control 15-AS-20241218095002

Allegation investigated: Staff did not promptly answer communications from resident's representative. Staff did not prevent a resident from inappropriately grabbing another resident.

On 11/12/2024 12:00 PM, Licensing Program Analysts (LPAs) James Sampair and David Doidge arrived unannounced at the facility to investigate the allegation above. Upon entry, the LPAs explained the purpose of the visit to Generations Program Director Ebony Foy. The complaint alleges that staff did not promptly answer communications from resident's representative. The LPAs interviewed Witness W1 and Director Foy. The LPAs reviewed email messages concerning the incident between Residents R1 and R2 as well as facility records and health records for Resident R2. The Director’s statement and the data reviewed did not support the allegation. Continued on LIC 9099-C... Unsubstantiated ...Continued from LIC 9099 The complaint alleges that staff did not prevent a resident from inappropriately grabbing another resident. The LPAs interviewed Witness W1 and Director Foy. The LPAs reviewed email messages concerning the incident between Residents R1 and R2 as well as facility records and health records for Resident R2. The data reviewed did not support the allegation. Although the allegations may have happened, or are valid, there is not a preponderance of evidence to prove them; therefore, the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 12, 2024 · control 15-AS-20241106155241

Type of visit: Case Management - Other

On 11/12/2024 at 12:00pm, Licensing Program Analysts (LPAs), D. Doidge and J. Sampair arrived unannounced to conduct a case management visit regarding an incident concerning R1 that occurred on 10/30/2024 that was reported to the Department on 11/02/2024. The LPAs met with Ebony Foy, Generations Program Director, and explained the reason for the visit. The incident on 10/30/2024 involved R1 injuring R2. LPAs reviewed R1s Physician's report, Service Plan and Progress notes. Ebony informed LPAs that facility is starting the process of evicting R1. Exit interview conducted. A copy of this report providedthe state’s words, verbatim · CDSS document, Nov 12, 2024

Allegation investigated: Staff engaged in a physically inappropriate interaction with resident Staff made sexually inappropriate comments towards resident Staff left resident on the floor after a fall for a prolonged period of time

On 10/31/2024 at 9:45am, Licensing Program Analysts (LPAs), L. Hall and David Doidge arrived unannounced to deliver complaint findings for the allegations above. LPA met with Ebony Foy, Generations Program Director and explained the reason for the visit. During the course of the investigation the Department conducted interviews with residents, staff/former staff, witnesses, and obtained and reviewed records, including death report for resident (R2). Allegation: Staff engaged in a physically inappropriate interaction with resident. On April 3, 2023, resident (R1) was interviewed at the facility regarding the allegation of being sexually abused by an outside agency staff (S4) in February 2021 while in Continued on LIC9099. Substantiated Continued from LIC9099. care. R1 stated that S4 would come in her room and tell her that he wanted to be her boyfriend and lifted her shirt and kissed her breast. R1 also stated S4 made inappropriate sexual comments referring to her private areas. S4 was employed through an agency called Serving Seniors Care from May 2020 to December 2021. Staff member (S5) revealed that R1 had complained that one of the outside agency staff was inappropriate towards her, but S5 never heard what the inappropriate behavior was. On April 27, 2023, the Department interviewed W1. W1 stated R1 had told him that one of the male staff members said disgusting things to her and the male staff member also kissed her breasts. An interview with Serving Senior Care staff, (S7), revealed that he/she was aware that S4 was harassing R1 and was aware that S4 had said something sexual to R1. During an interview with suspect, S4, admitted that he told R1 that he wanted to be her boyfriend, asked if he could kiss her, and stated that he made inappropriate sexual comments while he was changing her. S4 said he told R1 those things as a joke and that he knows that it was inappropriate. Allegation: Staff made sexually inappropriate comments toward a resident. Interview with R1 on April 3, 2023, revealed that S4 would come into R1’s room and tell R1 that he wanted to be her boyfriend and look at her naked body, which made R1 uncomfortable. S4 also used inappropriate sexual language to refer to R1’s private area. During an interview with S4 on June 15, 2023, S4 admitted to using sexual language and making inappropriate sexual comments towards R1. S4 stated he was joking and admits he was wrong in making those comments. Continued on LIC9099C. Continued on from LIC9099C. Allegation: Staff left resident on the floor after a fall for a prolonged period of time Based on an interview with S1 it indicated that R2 was receiving services through an agency called SafelyYou . This service is used to monitor resident unwitnessed falls. S1 stated the system is that if a resident falls, SafelyYou is alerted and immediately contacts the facility and if no one at the facility answers SafelyYou has an additional contact number for the staff at the facility. The staff answering the call from SafelyYou goes to check on the resident. On the day in question, the Department reviewed the time sequence received from the facility regarding R2’s unwitnessed fall and the total time to respond to R2 was 1 hour and 10 minutes. S10 stated she received three (3) calls from SafelyYou to check on R2 and she had notified the person on duty each time a call was received. During the interview with S2, she stated she was working on both floors on the day of the incident, and she did not answer the phone when the agency called because she thought it was a scam call. S2 also stated when S10 told her to check on the resident she then went upstairs to check on her. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. 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. Appeal rights and a copy of this report provided. Continued from LIC9099. residents. The med techs stated the steps are to push the cart to each room, pour the medication into a cup, pass the cup to the resident, and make sure the resident takes the medication. All three (3) also stated the medication cart is never left unlocked when unattended. The allegation is Unsubstantiated. Allegation: Questionable death During record review the Department reviewed the death report received from the facility on December 21, 2023, that stated R2 had expired, but did not state a cause of death. During the investigation the Department obtained a copy of R2’s death certificate; it stated R2’s cause of death as natural causes. Allegation: Staff did not ensure resident's dietary needs were met. The Department interviewed three (3) staff that worked in the kitchen. S13 stated he is given a form from the residents for room service which specifies the residents’ request. If a resident requests diary to be added to their food, it is put on the side not into the food. S14 stated the food that is taken to the residents’ rooms is put on trays and condiments are put on the side for them to add themselves. Based upon the interviews and information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 31, 2024 · control 15-AS-20230224104657

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Nov 1, 2024

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature... This evidence was not met by: Based on record review and interviews the Licensee did not comply with the section cited above in keeping resident free from humiliation, which poses a potential health and safety risk to person in care.the state’s words, verbatim · CDSS document, Oct 31, 2024

Plan of correction: Generations Program Director agreed to implement a plan on the hiring process from other agencies going forward to CCLD by POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Nov 1, 2024

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidence by: Based on interviews the Licensee did not comply with the section cited above in staff having dignity with residents, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 31, 2024

Plan of correction: Generations Program Director agreed to conduct an in-service training for all staff on personal rights and submit documentation to CCLD that the training has been completed by POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Nov 1, 2024

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary... In facilities licensed for sixteen or more, sufficient support staff shall be employed... Additional staff shall be employed as necessary... The licensing agency may require any facility to provide additional staff... This requirement was not met as evidence by: Based on interviews the Licensee did not comply with the section above in attending to resident needs which poses a potential health and safety risk for persons in care.the state’s words, verbatim · CDSS document, Oct 31, 2024

Plan of correction: Generations Program Director agreed to review the plan and retrain staff on YouSafely, and submit documentation to CCLD by POC date.

Type of visit: Case Management - Other

On 10/31/2024 at 11:15am, Licensing Program Analysts (LPAs), L. Hall and David Doidge arrived unannounced to conduct a case management visit. LPAs met with Ebony Foy, Generations Program Director and explained the reason for the visit. While LPAs were conducting a complaint investigation 15-AS-20230224104657 on 10/31/2024, during record review LPAs observed S2 was not fingerprinted or associated to the facility. LPAs were also informed the facility did not have a qualified and certified administrator. The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights providedthe state’s words, verbatim · CDSS document, Oct 31, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(d) · Plan of correction due date: Nov 1, 2024

(d) All individuals subject to criminal record review shall be fingerprinted and sign a Criminal Record Statement... 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 S2 fingerprinted and associated to the facility which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 31, 2024

Plan of correction: Generations Program Director agreed to have S2 fingerprinted and submit document to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(a) · Plan of correction due date: Nov 11, 2024

(a) All facilities shall have a qualified and currently certified administrator. ...and shall be on the premises a sufficient number of hours... When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications... to be responsible and accountable for management and administration of the facility... This requirement was not met as evidence by: Based on interview and observation the Licensee did not comply with the section cited above in having a qualified and certified administrator, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 31, 2024

Plan of correction: Generations Program Director agreed to hire a new administrator, and submit documents to CCLD by POC date.

Allegation investigated: Staff handled residents in care in a rough manner

On 9/13/2024 at 11:40AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct complaint investigation and deliver findings in regards to the allegation above. LPA met with Executive Director, Stephanie Brice and informed her the reason for visit. During the course of investigation, LPA interviewed 6 residents, 4 staff, and complainant. LPA obtained and reviewed documents including staff roster with contact numbers, staff schedule, physician's report, care plan, emergency information, care notes, incident reports, discharge documents, and staff termination documents. Interview with staff revealed that two staff (S7 and S8) was rough with residents during ADL (Activities of Daily Living) care. S1 and S5 stated that after reviewing the safety-you system, it was observed that S7 cause a resident to fall on two different days without injuries. The two staff were either terminated or resigned. (Continue on LIC9099C...) Substantiated 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. Staff do not provide adequate supervision to residents in care Interview with residents revealed that staff would always respond to call buttons and staff are available when needed. Interview with staff indicated facility has been using a third party agency to provide additional caregivers as needed. S1 stated there are a set of caregivers and med techs for Assisted Living and Memory Care separately for AM shift, PM shift, and NOC shift. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted. A copy of this report provided.the state’s words, verbatim · CDSS document, Sep 13, 2024 · control 15-AS-20230705164320

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Sep 23, 2024

Personal Rights of Residents in All Facilities. To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature... This requirement is not met as evidence by: Based on investigation, licensee did not comply with the section cited above by staff performing ADL care in a rough manner which poses a potential health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, Sep 13, 2024

Plan of correction: Executive Director has agreed to conduct training for staff and submit staff sign in sheet & materials to CCLD by POC date.

Type of visit: Required - 1 Year

On 08/08/2024 at 2:20 pm , Licensing Program Analyst (LPAs) Ardalan Gharachorloo and David Doidge arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director, Stephanie Brice and explained the purpose of the visit. LPA toured the facility including but not limited to 4 residents’ apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. LPAs observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 68 degrees F. The hot water temperature in a residents’ shared bathroom was measured at 116 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 detectors were in operating condition during visit. Fire extinguisher was last serviced on 07/11/2024. Emergency Disaster Plan was last posted on 06/28/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 06/28/2024. LPAs reviewed 5 residents records and 5 staff records, and all were complete. LPAs also reviewed a sample of resident’s medications. LPAs also reviewed the following files:LIC 500 Personnel Report,LIC 610E Emergency Disaster Plan, Current Administrator’s Certificate. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 8, 2024

Allegation investigated: Facility has no security at night Facility elevator does not work Staff does not timely assist resident

On 3/6/2024 at 8:30 AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to conduct a complaint visit. LPA explained the purpose of the visit with Executive Director Stephanie Brice. During the initial 10-day complaint visit. LPA interviewed staff, collected the following documents: Communications with Kone Response Service about elevator repairs, Call log for all residents for three days. On the allegation of: Facility has no security at night Based on records review and interview with S1 the facility does not have security at night. S1 explained that they do have 5 staff on duty between 11pm and 7 am and they lock and alarm the doors at night to prevent people from walking into the facility who are not apart of the community. The doors are locked from the inside and resident are able to exit if needed. The doors are alarmed and if the alarm is triggered an event will be added to the call log. Continued on 9099-C... Unfounded ...Continued from 9099 On the allegation of: Facility elevator does not work Based on records review and interview with S1 the facility has always had at least one working elevator. The facility has two elevators and if one is having issues, they communicate with Kone Response Service who is contracted to preform maintenance. S1 stated that they were having issues with one of the elevators at the end of February and was serviced on March 4th. On the allegation of: Staff does not timely assist resident Based on records review and interview with S1 the facility has a call log showing response times of all the residents who activate their waterproof pendants. This call log also records all of the door sensors for the stairwells, doors and garage. It is a different process to reset the sensors and it takes much longer than the call buttons, so it skews their average response time. Even with the skewed numbers their average time is 23 minutes. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. No deficiency observed or cited during this visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 6, 2024 · control 15-AS-20240228120918

Type of visit: Case Management - Health Checks

On 1/30/24 at 3:15 p.m., Licensing Program Analyst (LPA) Greg Clark conducted an unannounced case management visit as a result of this facility receiving residents from Vista Terrace of Belmont (VTB). LPA met with Stephanie Brice, Administrator (ADM) and explained the purpose of the visit. There are currently 2 residents from VTB remaining at this facility. ADM stated that R1 and R5 decided to stay at this facility. During the visit, LPA toured the facility including but not limited to the apartments where the residents from VTB resided (R2, R3, R4, R6 and R7). LPA observed that all the apartments were empty. There were no health/safety concerns during today's visit. No deficiencies cited during visit. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Jan 30, 2024

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct a case management visit 12/18/23 to verify if an individual is currently not employed at the facility. Based on evidence obtained during today’s visit, the LPA has verified the individual is not present, employed, or residing at the facility. LPA has advised the licensee to disassociate the individual from their roster and submit an updated LIC 500. Exit interview conducted and a copy of this report provided via email.the state’s words, verbatim · CDSS document, Dec 18, 2023

Allegation investigated: Staff are overcharging the residents services not received

On 11/30/2023 at 1:00PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct complaint investigation and deliver findings in regards to the allegation above. LPA met with Executive Director, Stephanie Brice and informed her the reason for visit. During the course of investigation, LPA interviewed 8 residents, 2 staff, and complainant. LPA obtained and reviewed documents including admission agreement, physician's report, care plan, monthly payments, email correspondence, and charges/payments ledgers. After reviewing the documents, it was observed that R2 was charged for tray services for the whole month in July 2023. However, R2 only had tray service for one day. Email correspondence revealed that R2's family notify the facility of the billing error on 7/1/2023. 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. Substantiatedthe state’s words, verbatim · CDSS document, Nov 30, 2023 · control 15-AS-20230801103354

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Nov 30, 2023

Additional Personal Rights of Residents in Privately Operated Facilities. To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers...and competency to meet their needs. This requirement is not met as evidence by: Based on investigation, licensee did not comply with the section cited above by charging R2 services that was not provided which poses a potential personal rights violation to the persons in care.the state’s words, verbatim · CDSS document, Nov 30, 2023

Plan of correction: Executive Director (ED) has refunded the overcharge fees to R2 and family. ED and staff did an audit for all residents in AL and MC for their level of services and monthly charges. Additionally, ED has created a billing procedure to prevent future billing errors and provided a copy to LPA during visit. Deficiency cleared.

Type of visit: Required - 1 Year

On 11/30/23 at 10:57 a.m., Licensing Program Analyst (LPA) G. Clark arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director, Stephanie Brice and explained the purpose of the visit. The facility’s fire clearance was approved for 186. LPA toured the facility including but not limited to 6 residents’ apartments, bathrooms, multiple activity rooms, kitchen, common areas and courtyard. There are no bodies of water observed. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 70 degrees F. The hot water temperature in a residents’ bathroom were measured at 116.8 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. LPA reviewed 5 residents records and 5 staff records; all were complete. LPA also reviewed a sample of resident’s medications. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 30, 2023

Type of visit: Case Management - Health Checks

On 11/30/23 Licensing Program Analyst (LPA) Greg Clark conducted an unannounced case management visit as a result of this facility receiving residents from Vista Terrace of Belmont (VTB). LPA met with Stephanie Brice, Administrator (ADM) and explained the purpose of the visit. There are currently 7 residents from VTB residing at this facility. During the visit, LPA toured the facility including but not limited to the 6 apartments where the residents from VTB reside. All apartments were fully furnished with a bed, chair, night stand, lamp and personal belongings. LPA observed an adequate supply of hygiene items in the resident's bathrooms. During the tour LPA spoke to 5 out of 7 residents. All residents expressed that they had all the supplies they need at this time. ADM reported that the VTB residents are tentatively scheduled to return to VTB in December 2023. Food, staffing and hygiene supplies were all observed to be adequate during visit. There were no imminent health/safety concerns on today's date. No deficiencies cited during visit. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Nov 30, 2023