Elegance Berkeley.

On 4/8/2026 at 12:30pm, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a Case Management visit. LPA met with Maureen Lee, Administrator, and explained the purpose of the visit. While LPA L. Hall was conducting a pre-licensing (CHOW) LPA observed one staff (S3) was not associated to the facility. LPA observed during record review that the ten (10) personnel files were incomplete. *An immediate civil penalty of $500.00 will be assessed on today's date for 87355 association to facility* Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of the LIC421BG, appeal rights, and this report provided.

On 08/26/2025 around 09:45 AM, Licensing Program Analysts (LPAs) L. Holmes and L. Alexander arrived unannounced for a required annual inspection. LPAs met with Annemarie Domizio, Executive Director (ED) and Maureen Lee, Memory Care Director (S2), and explained the purpose of the visit. ED was not available due to the activities taking place a the facility. The facility’s fire clearance was approved for one hundred twenty (120) non-ambulatory residents; ten (10) may be bedridden, and ten (10) hospice. Upon arrival, LPAs observed multiple staff organizing a residential Hawaiian Luau, the receptionist was attending to several residents and guest visiting in the facility. LPA L. Alexander toured the facility S2. The areas included but were not limited to the common areas, dining room, bathroom, kitchen, med tech room, fitness center and courtyards. The facility consists of individual apartments housed by the residents and has a monitored floor for memory care. All outdoor and indoor passageways were free of obstruction. There were no bodies of water present. A comfortable temperature was maintained at 74 degrees Fahrenheit (F). LPA observed lighting in all areas to be adequate for the comfort and safety of the residents. The hot water temperature in four different rooms measured at 108 to 120 degrees (F). The shared restroom had paper towels, soap and garbage cans; all areas were safe and sanitary. PPE, sanitizer, and paper goods remain sufficient. There was a 2-day supply of perishable foods and a 7-day supply of non-perishable foods. ...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 units were in operating condition during visit. Fire extinguisher was observed full and serviced 07/24/25. Emergency Disaster Plan is updated. Safety drills are rotational and last inspected 07/23/2025. LPA reviewed seven (7) staff files, and ten (10) resident files. -At 11:35 AM, LPA confirmed through Guardian, and CCLD staff support that S2 was not associated to the facility; corrected during the visit. -At 12:15 PM, LPA confirmed through observation and reviewed seven (7) out of seven (7) personnel records were incomplete; no health screenings, no first aid, insufficient training. Deficiencies are being cited on the attached LIC 809D. Civil penalties were assessed for $100.00/day x five (5) days. Failure to correct the deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties. LPA L. Holmes advised ED that the use of the name, "The Arbor at Berkeley" must cease until licensed which includes but is not limited to signs, documents, flyers and announcements. Exit interview conducted. A copy of this report and appeal rights provided to S2.

...continued from LIC9099. Allegations: SUBSTANTIATED Staff are not ensuring that resident(s) receive their medication's as necessary. S6 reported on R1’s progress notes dated 03/15/2025 that R1 last received Sertraline on 03/12/25; The Electronic Medication Administration Records (EMAR) further reports that Omnicare and Elegance Berkeley had two different attending physicians. As a result, W1 wrote a prescription on 03/17/25 and W2 provided the medication to the facility for R1. S6 stated that the R4’s medication was discontinued on 02/28/25, but R4 missed the medication for two days, R4’s family was not notified, and the doctors were not aware. S6 states, “Staff are not properly trained.” Staff are not adequately supervising resident(s) in care. On 03/04/25, S8 documented on R1’s progress notes that R1 was found outside by the corner of the facility. Records and interviews with S1, S2, S5, S6, S7 and W2 revealed that R1 has exited Memory Care and had wandering behaviors in March and April of 2025. On 04/14/25, R1 exited from Memory care to the 1 st floor without any staff witnessing the elopement. On 04/28/25, W2 requested that R1 take a stroll with the Care Companion (1:1), action was denied by S1 and S5. S2 confirmed that R1 was unable to leave with the 1:1 because the staff were trying to get R1 acclimated to residing in Memory Care. Licensee does not ensure that medical staff are able to communicate with staff regarding residents in care. W1, and S5 stated that the fax machine was not working but was not able to confirm the fax number; W1 stated the date was around January 2025. LPA confirmed that the fax number 510-788-XXXX is not working per the notification on the fax cover sheet from the facility dated 04/2025. W1 was not able to confirm the correct fax number because the facility had not given W1 any advance notification. LPA confirmed that 510-705-XXXX is a working fax, and was last tested 01/28/25 per records reviewed. 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 LIC9099C. Facility fax is in disrepair. W1, and S5 stated that the fax machine was not working but was able to confirm the fax number. LPA confirmed that the fax number 510-788-XXXX is not working per the notification on the fax cover sheet from the facility. W1 was not able to confirm the correct fax number because the facility had not given W1 any advance notification. LPA confirmed that 510-705-XXXX is a working fax and was tested on 01/28/25. 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 dates 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 to Justin Zackzewski, Director of Hospitality.

...continued from LIC9099. On 04/21/25, S1 submitted an LIC 624 stating. “The community will be seeking a three-day discharge” for R1; no Eviction Notice was provided to CCLD at that time. On 04/24/25, LPA requested the Eviction Notice that was provided to R1. On 04/28/25, S1 emailed LPA a 30-day notice of discharge addressed to W1 dated 04/22/25. On 04/29/25, LPA advised S1, S2, and S3 via email, W1 by voicemail on 04/29/25 and by phone conversation on 04/30/25 that the Notice of Eviction presented to R1 was unlawful, and that the facility’s Licensee would be required to provide notification to R1 and R1’s responsible party that the notice would be rescinded immediately. W1 was unaware of the notice, the details, and had not received any written Eviction Notice from any representatives from the facility. W1 provided proof of a formal notice hand delivered to R1 while in the community amongst other residents. R1 is currently admitted in Memory Care (MC) and the notice contained confidential information signed by residents R2, R3, and R4, other than R1. S2 confirmed that he.she was instructed by S1 to hand deliver the notice to R1 in the presence of other residents. Based on LPA’s interviews and records reviewed, the preponderance of evidence standard has been met; therefore, the above allegation is SUBSTANTIATED . Deficiency is 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, appeal rights and a copy of this report provided to Tsedey Mekonnen, Concierge..

On 02/05/2025 around 01:35 PM, LPA amended complaints 15-AS-20241223152240 and 15-AS-20241223091751 to update the continuation pages. Executive Director (ED), Annemarie Domizio suggested that Licensing Program Analyst (LPA) L. Holmes meet with Claudia Ridditt, Director of Business Administration (S1) due to ED's time constraints. LPA interviewed S5 to review the coding for the Medication Administration Records (MAR) and confirmed there will be initials for administration of medication, an 'X' or a blank space with progress notes for an explanation. On 01/21/2025, LPA requested ED provide proof that Residents (R2, R3, R4, R5) and their responsible parties were provided with a current incontinence care plan for the plan or correction on complaint 15-AS-20240917163033. On 01/28/25, LPA received the POC for training and updated care plans; however there were not any emails, faxes, or signed incontinence care plans from residents and RPs to confirm they were aware of the updates; during the visit, S1 and LPA reviewed signed copies for R1 and R3. S1 stated that they were awaiting the signed electronic documents from R5, and R2 had passed away. - Around 3:15 PM, LPA requested a Death Report (LIC624A) that revealed R2's date of death was 01/02/2025 and was reported to Community Care Licensing (CCL) 01/21/2025. Deficiency is 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, a copy of the appeal rights, and this report provided Claudia Redditt, Director of Business Administration (S1)

...continued from 9099. Staff left residents in soiled diapers for an extended period of time resulting in injury S17 reported he/she has often arrived for his/her shift to find residents were left wet, dirty, full of feces, and with red bottoms, specifically R6 and their family members were complaining directly to S17. S2 stated he/she has been the only one on his/her PM shift showering residents and has complained to S5. S2 has sometimes witnessed unkept faces, clothes, bedding, and soiled sheets because the AM shift hadn't changed the linen, redness in private areas from being soiled, and resident wounds in memory care. S3 stated that he/she is a Med. Tech. and have found residents on the couch with their entire bottom wet, or dried feces, and redness on their private areas. LPA interviewed W2, W2 stated there's been multiple times where R3's briefs and pants have been wet. On 01/03/24, W2 emailed ED and S8 requesting toileting every three (3) to four (4) hours for R3. W2 discovered there was urine on R3’s depends, pants, and wheelchair seat during a music session and that those discoveries were happening too often and was unacceptable. W3 states that R5 wreaks of urine. W3 changed R5’s soiled wheelchair cushion but was still unsure if the smell was coming from R5’s catheter or colostomy bag. W4 stated that R1’s sheets were soiled on a past occasions; therefore, W4 purchased additional sheets. The facility allowed R5 to leave the facility with another family and there was a hygiene issue. W4 didn't elaborate but was quite upset about the occurrence and it was concerning. W4 thought the incident was a form of neglect. W4 stated that if R1 was in his/her right mind, being constantly clean would be very important for R1. 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 LIC9099C Staff sleeping during work hours ED stated that S7 may have been sleeping on the second floor during his/her 15-minute break and that S7 has a medical condition. S17 and S18 reported they’ve both seen S7 sleeping when S7 should have been working, and that their co-workers may also be calling to make complaints. LPA and LPM interviewed S18 and he/she stated that a resident was walking by and S7 was snoring, and S18 reported the incident to ED and S5. Although S2 never saw S7 sleeping, S2 stated residents don't want S7 on their assignments and when S7 is working, he/she is also on the phone or watching television in the common areas. LPA reviewed S7's file and did not find any approved accommodations from the facility. Staff screamed at resident S2 said that there was screaming on the second floor coming from S15 who was not treating the residents on the floor with respect. S5 said that there’s no policies about the residents. S18 stated that he/she did not like the way S9 was talking to R2. S18 said that R2 is slow to respond sometimes and maybe the staff needs to be training on how to deal with residents. S18 further stated that another staff, S19, was screaming at a resident R2 on 09/17/24 at 11:30am. S18 stated that resident was refusing to go downstairs to the dining room and S19 started screaming, “You need to go now.” Based on LPA and LPM observations, interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations are SUBSTANTIATED . 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, appeal rights and a copy of this report provided to interim ED. 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 LIC9099A. Staff are eating residents food S17 alleged that S7 was eating R6’s food. ED and S16 were not aware of the allegation. LPA and LPM interviewed S1. S1 stated that he/she helps residents with lunch and dinner. S2 stated they’ve never seen anyone eating any residents’ food. LPA interviewed Witnesses; W2 stated that he/she didn’t have any other concerns about abuse or the staff's skill level or appropriate treatment. W3 stated it's hard to find someone at the facility sometimes and W3 hasn’t seen anything , W4 feels that the care staff are lovely. Staff is not allowing resident to watch TV S18 alleged that S7 puts the television (TV) on, and watches what S7 wants to watch and not what the residents want to watch. The facility has individual apartments and communal areas with televisions. LPA toured the facility, including the second floor on 09/24/24, 10/24/24 and 12/23/24. Multiple residents were not watching TV; instead, they were primarily engaged in other activities facilitated by the care staff. The second floor is memory care (MC). Residents that are able to communicate, can retreat to their individual apartments or sit in the lounge area where the television is located. A finding that the complaints are UNSUBSTANTIATED mean 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, appeal rights and a copy of this report provided to ED.

...continued from LIC9099. Allegations: SUBSTANTIATED Staff did not ensure residents room was kept safe, clean, and sanitary Staff did not ensure residents personal belongings were safely secured Staff did not ensure residents records were properly maintained Staff did not ensure residents medications were properly managed Staff did not ensure residents medications were dispensed as prescribed Staff did not ensure residents room was kept safe, clean, and sanitary. W1 reported during a visit the weekend of May 17 , 2024, R1's room was found with the waste basket overflowing with used depends, clothes and papers strewn over the bed, the room hadn't been vacuumed, laundry was undone, the bedding hadn’t been changed, and there was mold growing on R1’s plates that were left in the kitchen sink and open containers of food on the counter tops. S2 stated that it should not had mattered if cleaning is the job of housekeeping, R1’s room was untidy and R1 needed to be relocated for cleaning March 2024. S12 reported that the staff keep reporting things to S1 and nothing was being done, therefore the allegation is substantiated. Staff did not ensure residents personal belongings were safely secured. The above allegation refers to the facility not having an adequate policy in place to track residents’ laundry to prevent frequent losses of R1’s clothing which were either never returned or mistakenly worn by other residents according to W1. W1 and S2 stated that on that day of R1’s move-out, the caregivers on duty did not know which laundered items belonged to R1. The items are supposed to be labeled but normally are not, therefore the allegation is substantiated. Staff did not ensure residents records were properly maintained. R1 is diabetic and R1’s Functional Evaluation states that the MedTech is to cue R1 to perform a Finger Stick Blood Glucose (FSBG) test twice daily and there’s not any record of performance or denials of FSBG. The document created by S3 to capture R1’s blood sugar, only recorded the dates from 06/24/2024 to 07/23/24 out of the entire time of R1’s residential agreement from 11/22/23 to 08/10/24 therefore the allegation is substantiated. Continued on 9099C... 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 9099C. Staff did not ensure residents medications were properly managed. Per W1, S1 stated that R1’s critical medical documents were faxed to an unsecured public area. LPA, LPM and S7 toured the facility and there are not any facsimiles that were accessible to the public. S1 is no longer employed at the facility; however, LPA was able to review R1’s records and confirmed that a document for R1’s blood sugar was created by S3 per W1, S2, and S7; the document captured the dates of 06/24/2024 to 07/23/24 during R1’s residential agreement from 11/22/23 to 08/10/24 and there are no other documents for R1, therefore the allegation is substantiated. Staff did not ensure residents medications were dispensed as prescribed. Per W1, S1 stated that R1’s critical medical documents were faxed to an unsecured public area. LPA, LPM and S7 toured the facility and there were not any facsimiles that were accessible to the public. S1 is no longer employed at the facility; however, LPA was able to review R1’s records and confirmed that a document for R1’s blood sugar was created by S3 per W1, S2, and S7. S3 provided the electronic Centrally Stored Medication and Destruction Records for March 2024; when compared with the Medication Sheet for March 2024 it is inconsistent for the medication (Metformin) being dispensed or refused on the following dates of 03/19 - 03/25/2024 and 03/27 - 03/31/2024 therefore the allegation is substantiated. Continued on 9099C... 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 9099C. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. An immediate civil penalty of $250 is hereby assessed for a repeat violation times two (2). Deficiencies are cited from Title 22 California Code of Regulations and listed on 9099D. Failure to submit proof of corrections by plan of correction due dates and any repeat violation within 12 month period may result in civil penalties. Exit interview conducted, Appeal Rights, and a copy of this report provided to ED. 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 9099. Staff did not ensure resident received adequate laundry services. W1 presented photos of R1’s room the weekend of May 17, 2024, and none of the photo’s presented not laundered clothing or bedding. S12 presented photos of R1’s room on March 2, 2024, and none of the photo’s presented not laundered clothing or bedding. Although the bedding had clothes and paper strewn on top, LPA could not confirm or deny if the clothes or bedding were not laundered. After interviewing S2, S12 and W1. Interviews revealed the primary complaint was R1’s kitchen being uncleaned, therefore the allegation is unsubstantiated. Staff did not ensure resident received personal mail parcels. LPA observed S13 sorting mail. LPA had a conversation with S13 about trying to catch-up on all the different mail that came in over the weekend. W1 stated that R1's Google camera was missing and never delivered to R1 and provided a tracking number. LPA requested proof of delivery to the facility from W1. S1 is no longer employed for an interview regarding investigation of the missing parcel. After file review, LPA did not observe any complaints or a history of missing parcels, therefore the allegation is unsubstantiated. Staff did not ensure residents dietary care plan was properly followed. LPA toured the facility and observed a white board and dietary binder that listed the names and conditions of residents with dietary restrictions. S10 was aware that R1 was diabetic, and confirmed that S1, S10 and the kitchen staff met monthly to determine if meals needed to be modified or changed. S10 confirmed that the staff could not deny residents food but would steer them from carbohydrates, therefore the allegation is unsubstantiated. A finding that the complaint is unsubstantiated means that the allegations are not valid because the preponderance of the evidence standard has not been met. No deficiencies cited . Exit interview conducted, Appeal Rights, and a copy of this report provided to ED.

On 09/16/2024 around 01:50 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct an initial 10-day complaint visit and conducted a case management as a result. LPA met with Douglas Blake, Interim-Executive Director (ED) and explained the purpose of the visit. During the course of the visit, LPA conducted interviews with RP, ED and requested Resident (R1)’s file including, but not limited to the following documents from R1’s file: Physician’s Reports, Case Notes, Medication Administration Records, Centrally Stored Medication lists, UIR’s and faxes. -At 03:00 PM, LPA confirmed that Licensee did not report blood in R1’s urine on different occasions in April, July and August of 2024. -At 03:10 PM, LPA confirmed that R1 who has Dementia did not have an updated Physician’s Report (LIC602) or Reappraisal since 09/29/2022. -At 03:15 PM, LPA confirmed that there were medication errors on R1’s Medication Notification List faxed to the physician on 08/22/24. Staff did not report medication error to CCLD. -At 03:40 PM, LPA confirmed that there were medication errors on R1’s Medication sheet dated August 2024. Staff did not hold (discontinue) R1's medication starting 08/12/24 per physician's order. An immediate civil penalty of $250 is hereby assessed for the day of 09/16/24. Deficiencies cited from Title 22 California Code of Regulations and listed on LIC809D. 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.

...continued from LIC9099. For the allegation, Staff not administering medications to resident on multiple dates refers to dates 4/29/24, 7/4/24, 7/21/24, 7/26/24-7/29/24, 8/9/24, 8/20/24 for R1. Based on interviews with RP, ED and review of R1’s MD notification Form, Medication Administration Records and Centrally Stored Medication lists; the medications are inconsistent and there is not a clear legend to identify what the entries mean for each day entered. Licensee did not assure R1 received his/her prescribed medication on the noted dates. Deficiency 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 09/11/2024 around 9:50 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a case management. LPA met with Douglas Blake, Executive Director (ED) and explained the purpose for the visit. On 09/10/24, Licensing Program Analyst (LPA) L. Holmes requested R1’s LIC602 and LIC624 related to the R1’s Elopement. On 09/09/24, Licensing Program Analyst (LPA) T. Syess-Gibson conducted a phone interview per the request of Licensing Program Manager (LPM) to inquire about an AWOL that took place on 09/08/24 around 4:30 PM. LPA T. Syess-Gibson spoke with (S1), and explained the purpose of call. S1 offered to take the number and have Douglas Blake, Executive Director (ED) call back. At around 11:05 AM LPA T. Syess-Gibson received a call from Douglas Blake, Executive Director advising that the AWOL happened on 09/08/2024 at approximately 4:30pm with an Assisted Living Resident #1 (R1). S2 noticed R1 was missing and had left the community without signing out. The Berkeley Fire Department found the resident around 6:45-7:30 PM, and took the R1 to Alta Bates Hospital for observation hospital for observation. Per ED, the Aftercare Summary Report indicated a change in condition for R1 as an altered mental status. ED state that he has a call scheduled with the family to discuss R1’s long term care needs. LPA T. Syess-Gibson advised ED to send in the incident report as soon as possible. LPA T. Syess-Gibson provided ED with her email address and the office’s general email address. On 09/11/24 during the visit, ED confirmed that R1 can't leave unassisted and R1 may have left during the change of shifts at the Concierge area. Training on policies and procedures took place on 09/11/24. Unannounced drills will follow monthly along with bringing the teams together to review the policies, procedures, timelines, and debriefing regarding AWOLs/Elopements. 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... R1's responsible party and Berkeley Police Department were alerted immediately; however, Community Care Licensing was not notified until 09/09/24. -At 12:10 PM, LPA interviewed S2 and confirmed that S3 stated that he/she tested positive for COVID on or around 09/07/24; the incident was not reported to CCLD via telephone or fax. Based on information obtained, deficiencies are 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. An immediate civil penalty was assessed of $250 is hereby assessed on 09/11/2024. Exit interview conducted, Appeal Rights, and a copy of this report provided to Douglas Blake, Executive Director.

continued from LIC9099. During the course of the investigation, interviews and records reviewed revealed that on 09/07/23 and 10/21/23, S2 and S3 faxed notices to R1’s physician stating that R1 had been refusing to take his/her medication and requested that the physician advise R1. R1’s medication lists dated 09/20/23, 04/26/24 and 09/03/24 states that R1 has routine medication in the morning and evening (9:00 AM and 6:00 PM) and as needed based on R1’s systolic blood pressure. Records reviewied and interviews revealed that the facility did not have any record of R1’s refusal for medication, record of times of medication administration and there was not any notation or records of R1’s blood pressure. ED attempted to locate the information but stated that they were unable to recover the online data that was managed by a third-party vendor and a MAR was not utilized. Based on information obtained, the allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. 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.

On 09/03/2024 around 12:00 PM, Licensing Program Analyst (LPA) L. Holmes conducted a case management as result of an unannounced initial 10-day complaint visit. LPA met Douglas Blake, Executive Director (ED). During the course of the investigation and visit, LPA conducted interviews and requested R1's file including, but not limited to the following documents: Centrally Stored Medication Log, Medication Administration Records and Physician's Report (LIC602). -At 10:50 AM, LPA and ED reviewed R1's latest LIC 602 dated 06/06/2023. Deficiency cited to LIC D. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided to ED.

On 08/21/2024 around 09:30 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced for a required annual inspection. LPA met with Mary Anne Watral, Operations Specialist (OP) and Douglas Blake, Executive Director (ED) and explained the purpose of the visit. 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 several residents visiting in the facility's common area along with others eating breakfast. LPA toured the facility with OP and ED. The areas included but were not limited to, common areas, dining room, bathroom, kitchen, med tech room, fitness center and courtyards. The facility consists of individual apartments housed by the residents and has a monitored unit for memory care. All outdoor and indoor passageways were free of obstruction. There were no bodies of water present. A comfortable temperature was maintained at 73 degrees Fahrenheit (F). LPA observed lighting in all areas to be adequate for the comfort and safety of the residents. The hot water temperature in the shared restroom on the 2nd floor was measured at 117.1 degrees (F). The shared restroom had paper towels, soap and garbage cans; all areas were safe and sanitary. PPE, sanitizer, and paper goods remain sufficient. There is a 2-day supply of perishable foods and a 7-day supply of non-perishable foods. ...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 07/16/24. Emergency Disaster Plan is updated. Safety drills are rotational between monthly. LPA reviewed five (5) staff files, and seven (7) resident files. -At 10:15 AM, LPA confirmed through Guardian, and CCLD staff support that ED did not have criminal record clearance on file and was not associated to the facility. -At 01:25 PM, LPA confirmed through observation and review that seven (7) out of seven (7) personnel records were incomplete. OP and ED to review and update all files. Deficiencies are being cited on the attached LIC 809D. Civil penalty was assessed for $100.00/day Failure to correct the deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided to OP and ED.

Continued from LIC9099 R1’s ID/Emergency contact information, most recent Physician’s Reports and the report that the covers 09/2023 along with After Visit Summaries, Case Notes, and Centrally Stored Medication lists for 09/2023 - 10/2023; facility’s emails, faxes, call logs and/or any other correspondences with R1's Responsible Party (RP) and Primary Care Physician for 09/2023 and 10/2023. Allegation: Facility did not provide family with requested resident records. SUBSTANTIATED R1’s Responsible Party (RP) stated that on October 13, 16, 20, 21, and 24, 2023, that she/he had requested records pertaining to R1 and never received a response. ED does not have record of who the request was sent to at the facility. ED did not have who the POA was on record. On 06/14/24, interviews with Staff (ED and S1) revealed that R1’s resident files had not been provided to RP and there was not a POA on record. LPA spoke to ED and S1 on 07/16/24 and both stated that R1’s records would be sent to CCLD by the end of July. The facility did not provide family with requested resident records; therefore, the allegation is substantiated. Based on information obtained, the allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. 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 a copy of this report provided to Robert Coe, 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 ...continued fron LIC9099. R1’s ID/Emergency contact information, most recent Physician’s Reports and the report that the covers 09/2023 along with After Visit Summaries, Case Notes, and Centrally Stored Medication lists for 09/2023 - 10/2023; facility’s emails, faxes, call logs and/or any other correspondences with R1's Responsible Party (RP) and Primary Care Physician for 09/2023 and 10/2023. Allegation: Facility did not follow COVID procedures. UNSUBSTANTIATED On 04/06/23 California Department of Social Services (CDSS) presented PIN 23-07-ASC related to the COVID-19 pandemic following the end of the COVID-19 State of Emergency (SOE) on February 28, 2023, as guidance and to update licensees of Adult and Senior Care (ASC) facilities. On March 3, 2023, the California Department of Public Health (CDPH) terminated several State Public Health Officer Orders. Screening for COVID-19 signs, symptoms, and exposure were recommended for residents and visitors through passive screening measures but was not required. According to PIN 23-13-ASC, the licensee followed regulations related to infection control, prevention and mitigation for communicable diseases by maintaining an Infection Control Plan (ICP) and reporting the incident to Community Care Licensing (CCLD) on September 13, 2023; therefore, the facility did follow the COVID-19 procedures, and the allegation is unsubstantiated. No deficiency cited. Exit interview conducted and a copy of this report provided to Robert Coe, Executive Director.

Page 2 Staff allow a resident to be in soiled clothing for extended periods of time At complaint intake on August 30, 2023, the RP reported that on multiple occasions the RP had visited R1 and found R1 to be soaked in urine. On March 4, 2024, LPM Fong spoke with the RP who reiterated that R1 was found to be soaked in urine on multiple occasions and that this was brought to the attention of S4. On March 5, 2024, LPM Fong conducted a continuing complaint visit and observed that R1s MD report and intake Appraisal indicated that R1 was independent in toileting. On that same date, LPM Fong interviewed S2, S3, and S4 – all of whom were confirmed to have been employed during the subject time period. S2 reported having no knowledge of the issue, however, S4 acknowledged that family reported coming to the facility to find R1 soaked in urine. An internal investigation was performed, and it was determined that R1 had been left in urine soaked garments and bed for an extended amount of time. Updated Needs and Services documents from August, 2023, indicated that R1 did require incontinence undergarments and changing. Therefore, the allegation is substantiated. Staff do not properly maintain resident’s bedroom. At complaint intake on August 30, 2023, the RP reported that during multiple visits, R1's room was found to have urine soaked clothing and bedding strewn about and with strong urine smell. On March 5, 2024, LPM Fong interviewed S2, S3, and S4 – each stated having no knowledge of R1s room not being properly maintained, cleaned, or serviced. On March 8, 2024, LPM Fong spoke with W1 (neutral witness) who reported having visited R1 at the facility mid-morning and found the room to smell strong of urine – to the point where W1 could not stay in the room. W1 also reported that the laundry basket was full of urine soaked items and that W1 pulled the basket out of the room and requested staff to remove and launder. Therefore, the allegation is substantiated. ......continued on 9099C (page 3) 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 Page 3 Staff do not meet a resident’s incontinence needs while in care. Per the above, at intake the RP reported that R1s incontinence needs were not being maintained. On March 5, 2024, LPM Fong interviewed S2, S3, and S4. S3 reported being on the early morning shift and on multiple occasions immediately found R1 to have been left in urine soaked clothing and bedding. S3 stated that the NOC shift had not properly checked and changed R1 as needed prior to S3’s arrival, therefore, the allegation is substantiated. Staff did not safeguard resident’s personal belongings. At complaint intake, RP reported that R1s undergarments and assistive walking devices had gone missing, with no explanation. On March 5, 2024, LPM Fong interviewed S2, S3, and S4. S2 and S4 reported having no knowledge any items belonging to R1 going missing. However, S3, reported that on multiple occasions staff found that R1s assistive walking device was missing – sometimes it was found, other times it was not, or was found having been destroyed. S3 confirmed that family had to purchase a new assistive walking device, therefore the allegation is substantiated. Staff do not properly maintain the facility grounds. At complaint intake, the RP reported visiting the facility on multiple occasions and observing urine smell in common areas. On March 4, 2024, LPM Fong interviewed S1, S2, S3, and S4 who denied knowledge of urine smell or other maintenance issues. On that same day, LPM Fong observed a strong urine smell in the common area near the secondary/back exit from Memory Care. Therefore, the allegation is substantiated. Staff inappropriately removed a resident’s hygiene products while in care. At complaint intake, the RP reported having visited the facility and found that all of R1s personal hygiene products had been removed from the room. On March 5, 2024, LPM Fong interviewed S2, S3, and S4 – with S2 and S4 stating that there had been staff persons who took it upon themselves to remove and lock the residents’ hygiene products. R1’s Service Plan indicated R1 is able to keep non-toxic products (hand and body soap, toothpaste, shampoo) in R1’s room Therefore, the allegation is substantiated. .......continued on 9099C (page 4) 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 Page 4 Staff did not provide adequate supervision to a resident while in care. At complaint intake, the RP reported that on December 5, 2023, RP found R1 half-naked and wedged between the bed and the wall and that R1 had been able to exit the facility unsupervised (from the Memory Care Unit). On March 5, 2024, LPM Fong interviewed S2, S3, and S4, with all stating having no knowledge of either incident. No witnesses were identified. On that same day, LPM Fong observed that an incident report dated April 11, 2023, was submitted to CCLD indicating that 3 residents (including R1) had been able to exit the Memory Care unit on April 5, 2023. Two of the residents were found in the stairwell; however, R1 was not observed until 15 minutes later when staff noted R1 outside of the facility. LPM Fong reviewed the MD report which confirmed that R1 could not leave unassisted. Based on information obtained, the allegation is substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited from Title 22 California Code of Regulations and listed on 9099Ds. Failure to submit proof of corrections by plan of correction due dates and any repeat violation within 12 month period may result in civil penalties. Deficiencies and plan and proof of correction were discussed with the LaTiana James. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided. 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 Page 2 At complaint intake, the RP reported that R1 had been able to exit the Memory Care unit and the building without supervision. RP further reported being able to exit Memory Care by pushing the door, and that it was not secure. On March 5, 2024, LPM Fong observed that the main entry to Memory Care is accessed by taking the elevator to the second floor, and that an electronic key fob is needed to release the entry/exit door. From the inside, LPM Fong again found that the key fob is required to release the door. LPM Fong found that there is a second, back door exit leading to a stairwell that exits at the ground level. This secondary door was found to be a delayed egress. During interview, S1, S2, S3, and S4 stated having no knowledge of there being a maintenance issue with the Memory Care unit doors and no other witnesses were identified. It is undetermined whether R1 had been able to exit specifically due to failure to secure the facility grounds. Based on information gathered, the allegation is unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiency cited. Exit interview conducted and copy of this report provided.

On 08/15/2023 at about 10:10 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced for a required annual inspection. LPA met with Mary Anne Watral, Interim-Executive Director (ED) and explained the purpose of the visit. 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 (2) residents visiting in the facility's common area. LPA toured the facility with ED and Sergio Lepez, Director of Maintenance. The areas included but were not limited to, common areas, dining room, bathroom, kitchen, front area and courtyard. The facility consists of individual apartments housed by the residents and has a monitored unit for memory care. 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). LPA observed lighting in all areas to be adequate for the comfort and safety of the residents. The hot water temperature in the shared restroom was measured at 109.3 degrees (F). The shared restroom had paper towels, soap and garbage cans; all areas were safe and sanitary. PPE, sanitizer, and paper goods remain sufficient. There is a 2-day supply of perishable foods and a 7-day supply of non-perishable foods. ...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 07/10/23. Emergency Disaster Plan is updated. Safety drills are rotational between monthly. LPA reviewed five (5) staff records, and five (5) resident records. -At 11:15 AM, LPA confirmed through Guardian, and CCLD staff support that ED does not have criminal record clearance on file and is not associated to the facility. Deficiency is being cited on the attached LIC 809D. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided to ED.