Belmont Village Albany

On 3/24/2023 at 4:30PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit. LPA met with Executive Director, Tamra Tsanos and Assistant Executive Director, Rachel Kelly. While LPA was conducting a complaint investigation to deliver findings, the following deficiency was observed. During complaint investigation, it was observed that facility did not report the incident between R1 and R2 that occurred in December 2021. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights were provided.

On 7/21/2021 starting at 10:30am, Licensing Program Analyst (LPA) L. Ibo arrived unannounced to conduct an Infection Control Inspection. LPA met with Administrator, Michelle Moros and explained the purpose of the visit. During the Infection Control Inspection, LPA toured facility including but not limited to front entrance, screening station, hand washing stations, common areas, kitchen and lobby area. Facility has a sufficient 2-day perishable and one-week non-perishable food supply. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE (mask). Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has a mitigation plan and maintains record of routine screening for residents and staff. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

On 06/06/25 around 09:40 AM, L. Holmes, Licensing Program Analyst (LPA) arrived unannounced to conduct a case management for a Death Report, two (2) SOC341s and to discuss the outcomes. LPA met with Raquel Lozano, Business Office Manager (S1) and Ciara Flores, Memory Program Coordinator (S2); Jesus Gonzalez, Executive Director (ED) is not available at this time. During the visit LPA, S1 and S2 discussed Residents (R1, R2, R3, R4) LPA noted findings, ED to request a death certificate from the family and forward it to CCLD. S2 confirmed that R1 was not receiving hospice care and services. R3 and R4 resides in Memory Care (MC), the two grabbed each other while in passing which resulted in a physical altercation. Both families were notified, there has not been any addition problems between the two or complaints from the families. R3 currently has a personal one on one. S3 reported a potential incident of abuse that occurred on 05/15/25 against R2 from S4. The incident was self reported to CCLD, Empowered Aging and Albany Police Department via an SOC341. In service training provided to staff on 05/20/25. S4 was later terminated on 05/23/25. No deficiencies cited, exit interview conducted and a copy of this report was provided to Ciara Flores, Memory Program Director.

continued from LIC9099. Facility staff are not providing resident with appropriate supervision, resulting in falls. For the allegation, LPA reviewed Resident’s (R1, R2, R3, R4 and R5) resident records including but not limited to UIRs, Physician’s Report (LIC602), Centrally Stored Medication Reports, Care Notes, the schedule for The Neighborhood/Memory Care from 09/2024 - 10/2024, and R1’s consent for SafelyYou fall reduction. LPA confirmed R1 was diagnosed with Osteoporosis disease, had experienced fractures, had a common condition of mobility impairment that included use of walker if needed, and Dementia. Interviews with ED, Witness #4 (W4),and Staff (S2, S5, S6) revealed that not all R1’s fall were witnessed; however, falls that were unwitnessed and witnessed were documented on a UIR, 911 was activated and SafelyYou immediately reported falls to the concierge and nurse on duty. The facility appeared to be sufficient in staff when LPA reviewed the schedule for 09/2024 0 10/2024. LPA reviewed and confirmed the facility’s latest in-service and training plan of correction for all staff dated 10/08/2024 and 12/20/2024. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is UNSUBSTANTIATED . No deficiencies are being cited during this visit, exit interview conducted, and a copy of this report provided to Raquel Lozano, Business Office Manager

Page 2 LPA Delmundo obtained copies of resident roster and staff schedule and conducted interviews. Allegation: Staff are not responding to phone calls at the facility. FM1 stated that on 08/2023 facility has COVID-19 cases and FM1 called the facility and no one was responding. LPA Delmundo interviewed staff (S2, S3, S4 and AED) who all stated that never was there an occasion when facility phone was broken nor left unanswered. These staff stated there's always 2 staff in front - front desk and concierge - during the day and one at NOC shift. If the staff goes on break, another staff covers. LPA also interviewed a family member (FM2) who stated that whenever FM2 calls the facility, it goes through and answered. Therefore, the allegation is unsubstantiated. Allegation: Staff are not effectively communicating with residents and their families regarding COVID-19 outbreaks at the facility. FM1 stated the above. LPA Holmes interviewed staff (S1 and S2) who both stated they did what they need to do when it comes to reporting and that they are very involved in reporting. LPA Delmundo interviewed AED who stated that he sends email blast to the residents' family whenever facility has COVID-19 outbreak. LPA Delmundo reviewed the documents obtained during the course of investigation which showed that the facility sent email to the residents' responsible persons informing that the facility has positive cases of COVID-19. LPA interviewed FM2 who stated that FM2 receives notifications when facility has positive cases. Therefore, the allegation is unsubstantiated. Based on interviews conducted and records reviewed, the preponderance of evidence standard has not been met, therefore the allegations are found to be unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiency cited. Exit interview conducted and copy of this report provided.

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office , 1515 CLAY STREET, STE. 310 OAKLAND , CA 94612 This is an official report of an unannounced visit/investigation of a complaint received in our office on 09/02/2021 and conducted by Evaluator Alicia Delmundo -Resident (R1) lost a large amount of weight while in care. -Facility did not contact resident's (R1) representative on status of resident's health. -Facility did not adhere to the resident's (R1) care plan. -Resident did not receive medical care in a timely manner. On this day, 12/17/24, at 12:30 pm Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings for the above allegations. LPA met with Assistant Executive Director Erik Holzherr, and informed the reason for the visit. During the course of the investigation, the Department conducted interviews with staff (S1, S2, S3, S4, S5, S6, S7, S8, S9), resident (R4) and former executive director on 9/08/21, 4/17/23, 4/26/23, 5/15/23, 9/17/24 and 10/25/24. Resident’s family member (FM) was also interviewed. Resident (R1)’s record was reviewed and copies including but not limited to the following were obtained: LIC602A Physician’s Report; medical record; Unusual Incident Reports (UIRs); death report; weight record; doctor’s visit notes; health provider/medical professional’s correspondence to the facility; Medication Administration Record; doctor’s order of medications ...continued on 9099C (page 2) SUPERVISORS NAME : Bennett Fong LICENSING EVALUATOR NAME : Alicia Delmundo LICENSING EVALUATOR SIGNATURE : DATE: 12/17/2024 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office , 1515 CLAY STREET, STE. 310 OAKLAND , CA 94612 Page 2 Allegation: Resident (R1) lost a large amount of weight while in care. FM stated R1 lost 40 lbs while in facility’s care. Two of the 9 staff who provided care to R1 were interviewed. These 2 staff stated they noticed R1 losing weight but R1 at times refused to eat. When R1 refused to eat, they either changed the food, provide options or switch caregiver. Two facility LVNs and facility RN stated if resident lose weight they inform the resident’s primary care physician. Review of medical records showed that prior to R1’s passing away, R1 had appointments with medical professional of which FM brought up the issue of R1 losing weight; however, R1’s weight was not recorded due to the visits were virtual. On 4/07/21, the medical professional sent correspondence to the facility and requested to send R1’s weekly weight record. Weekly weight records from 4/05/21 to 7/23/21 ranged from 112 lbs to 120 lbs. LIC602A dated 5/04/21 showed R1 weight was 118 lbs. LPA was not able to interview R1 as R1 was no longer at the facility when complaint was received. Therefore, the allegation is unsubstantiated. Allegation: Facility did not contact resident's (R1) representative on status of resident's health. FM stated that on 8/03/21, day prior to R1 passing away, FM went to the facility and found R1 unresponsive with sunken cheeks and mouth open, and that the facility did not inform FM. Review of records showed that prior to R1’s death, facility’s hospice visit note dated 8/03/21 showed hospice agency staff were at the facility with FM. All 3 caregivers interviewed stated if there’s a change in resident’s condition, they inform the facility med-tech and/or nurse. All 4 facility nurses including Director of Resident Care Services (DRCS) stated they inform the resident’s family/responsible person and primary care physician (pcp) of the changes in resident’s conditions. DRCS also stated she conducts care conference with the resident's family and/or responsible person to discuss and let them know that she will contact the pcp. One of the facility nurse (S2) stated that if resident is on hospice and actively dying, they call hospice staff and resident's family to inform of the change in condition. Resident (R4) stated that the facility staff are good in providing update for him and his wife who is also a resident of the facility. Therefore, the allegation is unsubstantiated. .....continued on 9099C (page 3) SUPERVISORS NAME : Bennett Fong LICENSING EVALUATOR NAME : Alicia Delmundo LICENSING EVALUATOR SIGNATURE : DATE: 12/17/2024 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office , 1515 CLAY STREET, STE. 310 OAKLAND , CA 94612 Page 3 Allegation: Facility did not adhere to the resident's care plan. FM stated that it is in the care plan that staff agreed to weigh R1 regularly, but this did not happen. FM also stated the staff were not giving R1 pain pills and that FM fought to have staff continue the pain management. All staff interviewed stated that residents in the Memory Care are weigh every month. R2’s husband stated that R2 is weighed every month. Review of R1 record showed that on 4/07/21, R1’s medical professional sent correspondence to the facility and requested to send R1’s weekly weight records. Records from 4/05/21 to 7/23/21 showed R1 was weighed once a week. Review of resident’s record showed there were changes over time in R1’s doctor’s order of pain medications and the medications were administered. Therefore, the allegation is unsubstantiated. Allegation: Resident did not receive medical care in a timely manner. FM stated that on 8/03/21 FM came to the facility and found R1 unresponsive, with sunken cheeks and mouth open. R1 was taken to the hospital and died on August 4, 2021. FM also stated that FM believes that R1 should have been taken to the hospital sooner. Review of records showed R1 was placed and admitted on hospice care on 7/02/21 due to advanced dementia and failure to thrive. Staff interviewed stated that if resident is on hospice and actively dying, they call the hospice agency unless the resident fall or sustained head trauma, 9-1-1 is called. Records showed R1 was visited by hospice on the following dates: 7/06/21 to 7/09/21; 7/14/21 to 7/23/21; 7/26/21 to 7/30/21; 8/03/21. Death Report showed R1 passed away on 8/04/21 and death certificate showed senile degeneration of the brain as cause of death. Based on interviews conducted and records reviewed, the preponderance of evidence standard has not been met, therefore the allegations are found to be unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit interview conducted and copy of this report provided. SUPERVISORS NAME : Bennett Fong LICENSING EVALUATOR NAME : Alicia Delmundo LICENSING EVALUATOR SIGNATURE : DATE: 12/17/2024 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

On 12/12/24 around 10:40 AM L. Holmes, Licensing Program Analyst (LPA) arrived unannounced to conduct a case management for complaint #15-AS-20240716140724 received on 07/16/2024. LPA Jesus Gonzalez, Executive Director (ED) and explained the purpose of the visit. During the investigation of the above complaint, LPA interviewed ED, Staff (S1, S2, S3, S4, S5) Witnesses (W1, W2, W3, W4), obtained a resident roster, and requested the following for Resident #1 (R1): current Physician's Report, Admission Agreement, ID/Emergency Contact information, hospice care plan, care notes, incident reports, hospice notification, facility's regulations and documentation regarding Stage 3 and 4 pressure wounds, emails and/or written communications to R1's family regarding pressure wound injuries. -On 07/23/24, LPA requested R1’s Initiation of Hospice notification and Physician’s Report (LIC602) from S1. LPA requested the reports be provided to the Community Care Licensing Department (CCLD) by 07/30/2024 for preliminary review. The records weren’t provided to LPA during the investigation. -On 07/23/24, LPA requested R1’s Unusual Incident Reports (UIRs) from S1. R1 was transported to Alta Bates Medical Center in Berkeley for emergency services to treat a stage 3 to 4 pressure wound. Notification of deviation of R1’s hospice care plan on 07/14/24 was not provided to CCLD. Continued on LIC809C... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 ...continued from LIC809. -W1 and S5 confirmed that Private PALs were not available throughout the entire duration of R1’s admission agreement. The licensee did not provide any written notice (30 or 60 days) for the change in services noted below on pages 5, 10 and 30. Records and interviews revealed that W1 hired a private caregiver from 12/2022 to 07/2024 to aid in the care of R1. Page 5 II. Personal Assistance and Care “… Appendix A . We may change the scope and pricing of the services and our discretion upon sixty (60) days’ written notice to you. Page 10 C. Private PALs and Services from Home Health Agencies “To accommodate additional resident needs and preferences, we offer private care-giving and companion services for an additional fee as set forth in Appendix B ” Page 30. B. Termination by Us . (1) Upon (30) Days’ Notice . We may terminate this Agreement upon (30) days’ written and verbal notice to you and your personal representative if any of the following events occur: d. If, after admission, we determine that you have a need not previously identified and a reappraisal has been conducted pursuant to Section 87463 of Title 22 of the California Code of Regulations, and we and the person who performs the reappraisal believe that the community is no longer appropriate for you. Deficiencies are cited from Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violations within a 12-month period may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights were provided to ED.

...continued from LIC9099. Interviews conducted with the ED, S1, S2, S3, S4, S5, W1, W2, W3, & W4 confirmed that emergency services were initiated for R1 to be transported to Alta Bates Medical Center in Berkeley, CA for a stage 3 to 4 pressure wound. S2 stated that on July 14, 2024 a nurse’s aide (S4) called the paramedics, R1 was on hospice, under hospice care, and was being transported for 1st aid; W2 was present. W4 stated that W1 and W2 were blindsided; W1 and W2 did not know that the facility would not allow R1 to return after treatment of the wound on 07/14/24. W1, R1’s Power of Attorney (POA), was not present and was out of the country at that time. W4 further stated that S2 outright refused to accept R1 back to the facility although R1 was under the care of hospice. With the efforts of W4, R1 was successfully placed at another Residential Care for the Elderly (RCFE) in Pinole, CA with the services of Sutter VNAH Alameda Hospice. S2 did not seek counsel for joint determination from the Community Care Licensing Department (CCLD), the resident, R1’s Power of Attorney (POA), the hospice agency, physician, and licensee to determine that R1’s continued retention at the facility would pose a health and safety risk. Based on interviews and records reviewed, the preponderance of evidence for the violation has been met; therefore, the allegation is SUBSTANTIATED . Deficiencies cited from Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violations within a 12-month period may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights were provided to ED.

On 01/15/24 around 01:15 PM L. Holmes, Licensing Program Analyst (LPA) arrived announced to conduct a case management for complaint 15-AS-20241007145119 received on 10/07//2024, and to discuss two (2) reported elopements. LPA met with Jesus Gonzalez, Executive Director (ED) and explained the purpose of the visit. During the visit LPA and ED discussed Resident #1 (R1's) admission history, and reviewed Safely You footage for the investigation on the of the above complaint. LPA noted findings, ED will forward emails related to the complaint, staff and resident roster. ED reported on 11/19/24, R2 resides in Assisted Living, (AL) exited an alarmed back door at the facility around 4:30 PM. The concierge and caregiver intercepted R2 after the alarm and camera detection by 04:35PM. R2 has exiting behaviors, MD and Responsible Party (RP) were notified. Ed reported on 01/04/25, R3 resides in AL, exited through the main entrance of the facility around 2:00 PM. A caregiver intercepted R3 at the bus stop in front of the facility at 2:02 PM. R2 doesn't have exiting behaviors, will be monitored, MD and RP's were notified. No deficiencies cited, exit interview conducted and a copy of this report was provided to ED.

On 08/20/24 around 02:25 PM L. Holmes, Licensing Program Analyst (LPA), arrived unannounced to conduct a case management for an Unusual Incident/Injury Report (UIR) for Resident #1 (R1). LPA met with with Carol Blackwell, Director of Resident Care Services (S2) and Erik Holzherr, Assistant Executive Director (AED). LPA explained the purpose of the visit. Upon interviewing S2 regarding R1's bowel movements, S2 immediately knew who R1 was and stated that R1 resides in an Independent Living (IL) unit and that the caregivers would not normally keep record of the IL residents' bowel movements. Now that the facility is aware, there will be some follow-up conversations with R1 and R1's spouse to aid with R1's condition. AED confirmed that the UIR was sent to CCLD and was aware of the incident as Assisted Living (AL) and IL support both sides. No deficiencies cited. Exit interview conducted and copy of this report provided to Erik Holzherr, Assistant Executive Director (AED).

Residents are being neglected during overnight shift while in care Interview with residents revealed that staff would always respond to call buttons. R1 stated that overnight staff would come and check on R1 and pendent response time varies. Interview with staff indicated that if one staff cannot respond to call button, then another staff would get the call and would respond to the call button. Staff are not meeting the needs of the residents Interview with residents indicated that staff are good about assisting residents with ADL (Activities of Daily Living) care. R1 stated that staff assist with diaper changes and would always get help from staff. Interview with staff revealed that residents are checked for incontinence care at the beginning and end of each shift. S4 stated residents diaper changes are about 2-3 times per shift, but some residents are checked more frequent. Staff are yelling and mistreating residents Interview with residents revealed that staff are nice to residents and have not witnessed staff yell or scream at residents. R8 stated that staff treats resident well. Staff are placing residents in an unsafe environment Interview with residents and staff revealed that when staff mop the floors, there are yellow triangle signs that is put up warning of wet floors. Staff stated these signs are available at each floor for staff to put on the floor after mopping the floors. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore these allegations are UNSUBSTANTIATED . No deficiencies are being cited on this date. Exit interview conducted with Ciara Flores. A copy of this report provided.

On 08/20/24 around 02:25 PM L. Holmes, Licensing Program Analyst (LPA), arrived unannounced to conduct a case management for the recent diagnoses and relocation of Resident #1 (R1). LPA met with Jesus Gonzalez, Executive Director (ED) and Carol Blackwell, Director of Resident Care Services (S2). LPA explained the purpose of the visit. W1 email the following information to CCLD. R1 is a resident at Belmont Village Albany (BVA) and was admitted to the Highland Hospital in Oakland, CA after a fall at BVA during the night on 08/05/24. R1 has a severe fracture to the femur and hip area, and given his age, has decided not to receive treatment to repair the injury. R1 is expected to be completely bed-bound and receiving only pain and comfort medications. He is currently in a short-term skilled nursing facility (SNF), Richmond Post Acute. R1 require 24-7 care for his remaining time; R1 also has multiple other health conditions. The Unusual Incident/Injury Report (UIR) states that the incident occurred on 08/06/24 around 10:40 PM. W1 stated that in order to waive the 30-day termination notice requirement in the agreement, BVA is requiring a "health condition relocation order" from the Department of Social Services. Per Title 22 Division 6 Chapter 8 Article 11 Health-Related Services and Conditions, 87637 Health Condition Relocation Order is not initiated by R1 or W1 and the onus is on the licensee to follow the regulations. Given R1's current health condition and situation, LPAand ED discussed the options available to R1 and W1; R1 is currently at a SNF. ED stated that the 30-day notice had been activated by W1 and that he/she is willing to work with W1. LPA confirmed with Erik Holzherr, Assistant Executive Director (AED) that even if R1 is not returning to the facility, W1 would need to make arrangements to remove R1's personal belongings from the unit in order for maintenance to begin renovations and for BVA to retain a possible new resident. No deficiencies cited. Exit interview conducted and copy of this report provided to AED.

On 10/08/24 around 10:35 AM Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a case management. LPA met with Executive Director (ED) Jesus Gonzalez and explained the purpose of the visit. On 09/03/24, LPA L. Holmes received a call from LPA L. Fontanilla requesting COVID-19 status for Belmont Village Albany as a result of a UIR report presented to licensing. LPA L. Holmes requested that ED confirm the number of Staff & Residents that were COVID-19 positive and advised that both should be reported to CCLD as the facility becomes aware of the positive results. Through email, LPA was advised by ED that there were positive COVID-19 cases dated from 08/23/24 - 09/02/24 along with a spreadsheet. During the visit, ED provided LPA with a facsimile and Unusual/Incident Reports (UIRs). LPA advised ED of the regulatory guidelines for reporting infectious diseases within 24 hours. Based on information obtained a deficiency is cited from Title 22 California Code of Regulations and listed on LIC 9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violations within a 12-month period may result in civil penalties. Exit interview conducted, appeal rights, and copy of this report provided to Executive Director (ED) Jesus Gonzalez.

Continued from LIC9099. This agency has investigated the complaint and have found that the complaint was UNFOUNDED, meaning that the allegations were false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report provided.

On 07/03/2024 around 12 :30 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a required annual inspection. LPA met with Erik Holzherr, Assistant Executive Director (AED) and explained the purpose of the visit. The facility’s fire clearance was approved for 225 non-ambulatory, 50 may be bedridden and 20 are approved for hospice waivers. Upon entry and during the visit, residents were lounging in the facility including but not limited to the common areas, bistro, and courtyard area. The facility has a central medication room that remains locked. First Aid kits are stored throughout the facility. Smoke/carbon monoxide detectors are combined with sprinkler system. Fire extinguisher was last serviced on 05/16/2024. Fire drills are performed monthly and an annual evacuation is performed in conjunction with the local police department. Lunch was served while at the facility. Residents reside in individual apartments and the hot water temperature was a comfortable temperature with the censored faucet in the residents' shared bathroom. There was adequate lighting throughout the facility. Indoor and outdoor passages were free of obstruction. Last fire drill was conducted on 06/2024. LPA reviewed ten (10) resident records and 5 staff records. LPA also reviewed a sample of residents' clinical files. Exit interview conducted and copy of this report reviewed with Erik Holzherr, Assistant Executive Director.

Based on AGPA and LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . California Code of Regulations (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D. Exit interview conducted. Appeal Rights and a copy of this report provided to Executive Director. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 It was alleged facility failed to provide adequate staffing levels. However, based on interview with staff, if a staff is unable to report to work, then residents assigned to that staff will be distributed to the staff that are scheduled to work. S3 and S4 stated that caregivers in assisted living would assist in memory care if needed to. It was alleged there are unqualified staff working at facility. However, AGPA reviewed a sample of staff records on 7/20/23 and observed staff had completed the required training. It was alleged resident was left in soiled diaper and bedding at an extended period of time. Interview with 5 staff revealed that residents are checked every 2 hours or as needed. S4 stated most caregivers are familiar with the residents that staff are assigned to and how frequently those assigned residents needs to be checked. AGPA attempted to interview 3 residents, but AGPA was unable to obtain additional information. AGPA was unable to prove or disprove allegation. It was alleged facility is not kept clean. However, interview with staff revealed that dining room tables are cleaned after every meal. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED . Exit interview conducted and a copy of this report provided to Executive Director.

On 2/27/2024, at 10:00am Licensing Program Analyst (LPA) L. Hall conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 2/14/2024. LPA met with Executive Director, Jesus Gonzalez and explained the purpose of the visit. The incident report received stated that Resident 1 (R1) was observed walking back into the community through the front door by the concierge. Record review of R1's physician's report dated 3/21/2023, indicated that R1 is not able to leave the facility unassisted. Staff 2 (S2) stated that staff checked cameras and did not catch her leaving, but there are exits where a PIN code is not needed and staff assume R1 left through rear door. LPA obtained a copy of the staff roster, resident roster, Resident 1 (R1) physician's report and progress notes for the month of February during the visit. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of appeal rights and this report was provided.

LPA observed that R1 was re-evaluated in December of 2021 after the incident. S2 stated options were discussed with R1's family to prevent future incident and staff are always observing residents to see if assistance is needed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is UNSUBSTANTIATED . Exit interview conducted. A copy of this report provided.

...continued from LIC9099 During the investigation, LPAs interviewed three (3) Staff (ADM, S1, S2) and one (1) Witness (W1), collected and reviewed documents. Records and interviews revealed although R1 was a fall risk, R1 resided on the Independent Living side and was transferred to Assisted Living on . R1’s Admission Agreement signed 07/14/2017, effective 07/29/17, stated the following: Apartment Type: Large Sierra -IL, Apartment Number: 316, Service Plan Type: Independent Living. The facility’s Nurse Notes documented a history of witnessed and unwitnessed falls from 02/18/20 to 08/22/20; on 06/25/20, S2 recommended a higher level of care for R1 which would also more cost effective. S2 stated that they were calling R1's son very regularly but was adamant about R1 maintaining his/her independence. The facility's policy for head injuries is to call the medics immediately. R1’s son provided the facility with rubber non-skid products to reinforce R1’s bed legs and S2 witnessed a rug in place to mitigate the falls. Page sixty-eight (68) states R1 was assigned to apartment (apt) 223 in Memory Care but addendum was corrected to apt 331 for Assisted Living. R1 was receiving Hospice services and died 12/29/20. 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 to Tamra Tsanos, ED

On 07/20/2023 at 09:40 AM, Licensing Program Analyst (LPA) L. Holmes and Associate Governmental Program Analyst (AGPA) L. Francisco conducted an unannounced annual inspection. LPA/AGPA met with Tamra Marie Tsanos, Executive Director (ED) and explained the purpose of the visit. LPA L. Holmes toured the facility with (ED) who currently holds a certificate (#604 9144740) that expires on 05/07/24. The facility’s fire clearance was approved for two hundred twenty-five (225) non-ambulatory residents; fifty (50) may be bedridden. Upon arrival, LPA observed one (1) staff attending the receptionist desk, and two families visiting in the facility's common area. LPA, ED, and two (2) staff members toured the facility, including but not limited to, common areas, wellness center, library, bathrooms, kitchen, dining room(s), medication room/nursing station, front area and courtyard(s). The facility consists of individual apartments housed by the residents and has a monitored unit for memory care (The neighborhood). All outdoor and indoor passageways were free of obstruction. There were no bodies of water present. A comfortable temperature was maintained at 71 degrees Fahrenheit (F). LP A observed lighting in all areas to be adequate for the comfort and safety of the residents. The hot water temperature was measured at 111.2 degrees (F). All shared restrooms, hand washing, and bathing areas were safe, sanitary and in operating condition. Hand washing signs, paper towels, and soap observed at all hand washing stations. Linen and hygiene products are available for all residents. PPE, sanitizer, and paper goods remain sufficient. ...continued on LIC9099C. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 ...continued from LIC9099. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was observed full and serviced 04/06/23. Emergency Disaster Plan is updated. Safety drills were last conducted 06/2023 and are rotational between AM and PM schedules monthly. AGPA reviewed five (5) staff records, and all staff have criminal record clearances. Five (5) residents records were reviewed and are complete. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided to ED.

On 4/11/2022 Licensing Program Analysts (LPAs) L. Ibo & L. Francisco conducted a health and safety check as a result of department receiving a priority 2 complaint. LPAs met with Rachel Kelly, Assistant Executive Director and Zachary Striplin, Wellness Nurse. Facility has census of 187 during todays visit. During the health and safety check, LPAs toured the building, LPAs inspected common areas, bathrooms, kitchen and dining. LPAs observed smoke detectors and carbon monoxide detector throughout facility. Water temperature was checked at one common bathroom with a temperature of 106.4 degrees Fahrenheit. Enough food supplies was observed. Facility is maintained at a comfortable temperature for the residents in care. First aid kit was observed to be complete. Fire Extinguisher last service date was December 13, 2021. Due to facility's current gastrointestinal outbreak, LPAs was not able to visit residents room, however LPAs observed residents at the common area appeared to be well groomed, neat and comfortable. Facility appear to be safe and there are no imminent health/safety concerns on today's date. No deficiencies were cited today.

On 12/28/2021 Licensing Program Analyst (LPA) L. Holmes and Licensing Program Manager (LPM ) Y. Flores-Larios arrived unannounced to conduct a case management visit. At 1:10 PM, LPA and LPM met with Michelle Moros, Executive Director and explained the reason for visit in response to an incident report received on 12-08-2021 where R1 was absence without leave (AWOL). LPA conducted interview with Executive Director and toured the memory care unit "The Neighborhood" located on the second floor. On 11-25-2021 a LVN was conducting usual rounds, LVN noticed that R1 was not in her room. Facility staff immediately searched the facility and surrounding areas, R1's family was notified, and Albany Police Department was notified as well. R1 was located and returned unharmed. Facility suspects that R1 left through the front door as other resident's families were entering and exiting with residents from outings for Thanksgiving. Facility has implemented procedures in the event of an influx of visitors. No deficiencies are being cited on this visit. Exit interview conducted and a copy of this report provided

The Department investigated and found that R1 sustained severe bruising due to improper handling during transfers. From documents obtained and reviewed, R1 has a history of bruising and taking baby Aspirin daily. R1’s responsible party had discussions with staff and administrator regarding R1’s propensity to bruise easily and effective handling practices to minimize R1 bruising. However, even after these discussions, R1 sustained severe bruising because of staff’s failure to utilize proper handling techniques. R1 reported the bruises were from staff grabbing her on the legs and arms possibly to keep her from falling. W1 stated that R1 is able to stand by herself without assistance. W1 witnessed an incident when R1 was lying in bed and taking a while to get out of bed, staff grabbed R1’s arm to help pull her up off the bed. Interview with S1 revealed that an Amazon echo dot device was found in R1’s room. S1 stated that the device was removed on 4/28/2020 and returned to R1 on 4/30/2020. S1 stated that the device had audio capability which violated facility’s admission agreement. However, S1 later discovered that the device’s audio capability was disconnected. In the email correspondence with R1’s responsible party dated 4/28/2020, S1 stated the device was removed from R1’s room on 4/27/2020. Based on the department’s investigation, the preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED . California Code of Regulations, Title 22 is being cited on the LIC 9099D. A $500.00 immediate civil penalty is being assessed on this day. Civil penalty determination related to serious bodily injury is pending. Exit interview conducted. A copy of this report, civil penalty, and appeal rights provided.

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office , 1515 CLAY STREET, STE. 310 OAKLAND , CA 94612 This is an official report of an unannounced visit/investigation of a complaint received in our office on 04/07/2022 and conducted by Evaluator Leslie Ibo Resident developed skin tears while in care. Resident developed an infection while in care. Medical treatment was not sought for resident in a timely manner. Resident's medical records are not being maintained properly On 01/19/2023 at 10:15AM, Licensing Program Analyst (LPA) L. Ibo arrived unannounced to deliver complaint findings for the allegations above. Upon arrival, LPA met with Rachel Kelly, assistant executive director and explained the reason for the visit. During the course of the investigation, the Department conducted interviews with staff, residents, health providers, and complainant. Medical records and facility file, incident report, and facility’s correspondence with health providers were obtained and reviewed. Allegation: Resident developed skin tears while in care. Based on interview and records review, on 02/24/2022 facility staff reported that R1 sustained skin tear on her shin while staff was transferring R1 from wheelchair to the shower. Records review and interview stated that basic first aid was rendered to R1’s skin tear. Based on interviews with staff, R1 has very fragile skin that she needs to use shin guard. …Continues to LIC9099C… SUPERVISORS NAME : Harpreet Humpal LICENSING EVALUATOR NAME : Leslie Ibo LICENSING EVALUATOR SIGNATURE : DATE: 01/19/2023 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office , 1515 CLAY STREET, STE. 310 OAKLAND , CA 94612 Allegation: Resident developed an infection while in care. Based on records review, on 3/2/2022 R1 was taken to urgent care, records review revealed that R1 was diagnosed of infection. Allegation: Medical treatment was not sought for resident in a timely manner. Based on interview and records review, on 2/24/2022 at 10:00AM staff informed facility nurse that R1 was sustained skin while staff transferring her from wheelchair to the shower. Basic first aid was rendered, and family was informed. However, R1 was not sent out to urgent care nor 9-1-1 not until around 3:00PM 02/24/2022. Allegation: Resident's medical records are not being maintained properly During the course of the investigation, records review revealed that facility failed to update a new physician’s report for R3, the last physician’s report was dated 04/2021. The preponderance of evidence has been met. Therefore, the allegations above are substantiated. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POCs) 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. SUPERVISORS NAME : Harpreet Humpal LICENSING EVALUATOR NAME : Leslie Ibo LICENSING EVALUATOR SIGNATURE : DATE: 01/19/2023 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office , 1515 CLAY STREET, STE. 310 OAKLAND , CA 94612 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 requirement is not met as evidence by: Facility has agreed to re-train all staff on proper transfer techniques when transferring residents. Facility will submit training materials and staff sign in sheet to CCLD by 02/03/2023. Based on investigation, licensee did not comply with the section cited above resulting R1 sustaining skin tear due to improper handling during transfer which poses an immediate health and safety risk to the residents in care. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional..... This requirement is not met as evidenced by: Facility will train all staff on documenting residents' observation and will submit staff sign-in sheet to CCLD by POC date. Based on interview and records review, the licensee did not comply with the section cited above by not properly observing resident's changes in condition. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. SUPERVISORS NAME : Harpreet Humpal LICENSING EVALUATOR NAME : Leslie Ibo LICENSING EVALUATOR SIGNATURE : DATE: 01/19/2023 CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office , 1515 CLAY STREET, STE. 310 OAKLAND , CA 94612 Incidental Medical and Dental Care The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including... This requirement is not met as evidenced by: Facility will train all staff on the regulation cited above, a cpy of training with staff names and signatures will need to be submitted to CCL by POC date. Based on record review and interviews, Licensee did not comply with the regulation above, facility failed to take R1 medical facility or to call 9-1-1 in timely manner after sustaining skin tear, which poses an immediate health and safety risk to residents in care. CARE OF PERSONS WITH DEMENTIA (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5)Each resident with dementia shall have an annual medical assessment as specified...least annually.. This requirement was not met as evidenced by: Assistant Executive Administrator agreed to submit a up to date physician's report for R3, to CCL by POC date. Based on record review, Licensee did not comply with regulation cited above. On 01/19/2023 LPA observed R3's medical assessment was last completed on 04/2021 which poses a potential health and safety risk to persons in care. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. SUPERVISORS NAME : Harpreet Humpal LICENSING EVALUATOR NAME : Leslie Ibo LICENSING EVALUATOR SIGNATURE : DATE: 01/19/2023 CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office , 1515 CLAY STREET, STE. 310 OAKLAND , CA 94612 This is an official report of an unannounced visit/investigation of a complaint received in our office on 04/07/2022 and conducted by Evaluator Leslie Ibo Resident sustained multiple unexplained bruises while in care Resident developed a rash while in care Incidents involving resident are not being reported to their Resident Representative Admissions agreement is not being adhered to Resident's toileting needs are not being met while in care Medications are not being administered to resident according to their physician's orders. Insufficient staff On 01/19/2023 at 10:15AM, Licensing Program Analyst (LPA) L. Ibo arrived unannounced to deliver complaint findings for the allegations above. Upon arrival, LPA met with Rachel Kelly, assistant executive director and explained the reason for the visit. During the course of the investigation, the Department conducted interviews with staff, residents, health providers, and complainant. Medical records and facility file, incident report, and facility’s correspondence with health providers were obtained and reviewed. Allegation: Resident sustained multiple unexplained bruises while in care Based on the records review, R1’s assessment done on 02/27/2020 and re-assessment, it was indicated that R1 has a fragile skin and bruises easily and staff was ordered to be gentle while rendering care to resident. Records review also revealed that staff reported informed family about their observation on R1’s discoloration of right thigh and knee, staff applied cream per doctor’s order. …Continues to LIC9099C… SUPERVISORS NAME : Harpreet Humpal LICENSING EVALUATOR NAME : Leslie Ibo LICENSING EVALUATOR SIGNATURE : DATE: 01/19/2023 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office , 1515 CLAY STREET, STE. 310 OAKLAND , CA 94612 Allegation: Resident developed a rash while in care Records review revealed that on 04/04/2022, staff observed redness on R1’s skin, family was notified and R1’s physician was notified. Nurses’ notes revealed that staff followed as needed doctor’s order to apply nystatin powder on the affected area. Allegation: Incidents involving resident are not being reported to their Resident Representative Based on interview and records review; staff notified R1’s family when there is a new observation or any change of condition. Allegation: Admissions agreement is not being adhered to During the investigation, RP did not specific deficiency that was called out regarding admission agreement. LPA conducted records review, based on records review admission agreement was completed according to regulations. Allegation: Resident's toileting needs are not being met while in care During the course of investigation, records review revealed that R1 had toileting assistance of taking her to the bathroom 2-3X while awake and at least 5x during night shift. Interview with staff revealed that residents who needs incontinence care is checked 3-4 times per shift on residents with incontinence care/toileting needs. However, when residents have a bowel movement or an accident, staff will change and clean residents right away. During LPA’s visit, LPA c