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 05/02/2025 around 01:00 PM, Licensing Program Analyst (LPA) L. Holmes conducted a case management as result of a complaint dated 04/22/2025 #15-AS-20250422160308 and UIRs. LPA met with Justin Zackzewski, Director of Hospitality. In addition to the complaint, LPA received LIC 624 dated 04/24/25 stating that R1 was sent out (to the hospital) for repeated exit seeking. On 05/02/2025 around 1:10 PM, LPA toured the perimeter of the facility and observed a gray, cable wired, combination lock on the side gate. This gate exits from the facility's court yard. LPA advised S1 to remove the lock. 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facility’s Licensee would be required to provide notification to R1 and R1’s responsible party that the notice would be rescinded immediately. Continued on LIC 809C... 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 LIC 809. On 04/29/25, LPA advised S1, S2 and S3 that the notice and the previously noticed deadlines for eviction were invalid. LPA reviewed the eviction notice. Per Title 22 87224 Eviction Procedures, the Licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons. In addition, the exact statement as specified in Title 22 for an unlawful detainer shall be documented; these items were not documented. *An immediate civil penalty of $500.00 will be assessed on today's day for fingerprint clearance* Deficiency 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 LIC421M, appeal rights, and this report provided.

***CONTINUE FROM 9099*** During the visit, LPA with Justin Zackweski, Regional Director and LPA Lisha Holmes checked R3’s room. LPAs observed the room to be clean, organized and odor free. Staff interviewed state incontinent residents get changed 2-3 times during each shift. The first check/change is done at the start of shift, then after lunch and before end of shift. Allegation: Staff does not ensure adequate food options are available for residents with dietary restrictions - Unsubstantiated During the course of investigation, LPA reviewed facility menus for the last three months. There are two types of menu: regular and alternate. Interim ED states the regular menu has always two options for the residents to choose from. And then the alternate menu which can be served to the residents anytime they prefer to eat food apart from the regular. The information provided by the ED was confirmed by R3 who states that R3 has chosen the alternate menu a few times since living at the facility and everything is fine. An interview was conducted with R4 who states that R4 has dietary restrictions – Kosher diet, which the facility does not accommodate. R4 states the facility does not provide Kosher foods. When asked if the facility was made aware of R4’s restrictions during the admission process, R4 stated the facility should know but did not provide any further information. A review of R4’s medical assessment did not indicate any dietary restrictions or allergies. The report indicates R4 “has no special diet but has dietary preference .” The facility’s dietary board did not indicate R4’s name as one of the residents with dietary restrictions. Based on interviews and record reviews conducted, the above allegations are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. A copy of this report was provided to Sarian Lichtenberger, Regional Operation Leader .

Allegation: Staff does not prevent resident from being verbally abusive to other residents Investigation Finding: Unsubstantiated On 12/10/25 at 1:20PM, LPA interviewed staff (ROL, AED), staff incident statements and reviewed R1’s documents. ROL stated that they have had two in person meetings with R1 and R2 to address and mitigate their verbal altercations. AED stated that on 11/20/25 after residents had their lunch, staff (S1,S2) safely redirected R2 back to his room when he started yelling at R1 when she purposely provoked R2 to make him more angry. Prior LPA L Holmes' interviews with residents (R1,,R3, R4) on 09/04/25 confirmed that staff safely redirected and separated R1 and R2 whenever they had a heated argument. 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 that staff does not prevent resident from being verbally abusive to other residents is unsubstantiated. Allegation: Staff charging resident for services not received Investigation Finding: Unsubstantiated On 12/10/25 at 1:20PM, LPA interviewed staff (ROL, AED) and reviewed R1’s documents. Review of R1’s signed service plan agreement dated 04/22/25 showed R1 agreed to pay the Level I Assisted Living Care monthly charge of $960.48 effective 05/13/25. AED stated the change of monthly charge was due to the switch from Elegence at Berkeley Service Plan point system to the new Arbor at Berkeley Level of Care Plan system. Staff (ROL,AED) stated they explained the monthly service rate change to R1 and did not bill her the Level 1 Care package until 07/01/25 with a monthly discount of $200. 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 that staff is charging resident for services not received is unsubstantiated. No deficiencies cited. Exit Interview conducted and a copy of this report provided.

Facility Type: RCFE Application Type: Initial Capacity: 120 Census (if any clients in care): None Method: Telephone call with CAB COMP II Participants: Kenneth Assiran, Applicant; Andrew Badoud, Administrator; Chason Archuleta, Vice President Applicant/administrator participated in COMP II via telephone call with the analyst at CAB. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Staff qualifications and responsibilities 3. Applicant and Administrator qualifications 4. Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions 5. Grievances, Complaints, Community resources 6. Physical plant, food service 7. Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of property

On this day, December 8, 2025, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a health and safety inspection as a result of the Department receiving a priority 1 complaint (Complaint # 15-AS-20251203154452). LPA met with Associate Executive Director Justin Zackzewski and informed the reason for visit. LPA also met with Regional Operations Leader Sarian Lichtenberger. LPA selected total of 5 residents apartments on second, third and fourth floors for inspection. LPA also inspected the common areas including but not limited to the dining area, activity room and hallways. No deficiency observed during today's inspection. Exit interview conducted and copy of this report provided.

...continued from LIC9099. Staff did not prevent resident from harassing another resident. R1 stated that R2 was verbally harassing him/her multiple times. In a prior to the complaint is when R2 used a curse word towards R1. R1 did not identify any witnesses. S2 and S5 stated that R2 does have occasional outbursts which may be due to a medical condition, but there’s never anything physical towards R1. S2 stated that he/she spoke to R1 and R2 regarding the interactions suggesting sitting away from each other and/or repositioning R1's chair for avoidance, and S2 will redirect when necessary; stating that both residents have personal rights. R1 requested LPA to allow him/her to remain anonymous with R2; therefore, LPA did not interview R2. S5 stated that the allegation is not surprising because R1 will go behind the bistro bar even though R1 is not supposed to enter the area, and R1 does not want R2 to say anything about it him/her, becomes rude, screams, complains and then acts as if nothing has happened. Staff did not provide resident with adequate food service. LPA toured the dining area and observed breakfast and lunch being served to residents on 08/26/25 and 09/04/25. The purchase orders and invoices from Vesta and Sysco food services for the month of August 2025, were consistent with the menus provided and the meals observed. Interviews revealed that S1, S2, S3, S4, W1, W2, W3, R1, R3 and R5 did not initiate any complaints about the meals, menu of food provided; R1 was not forth coming with names, dates or times of the allegation or when the incident was reported. Licensee did not provide adequate notice of fee increase to resident. Interviews with (S1, S2, S3 S4), Admission records and services fees reviewed for R1, R2, R3, and R4 did not reveal any rate increases, improper notices or advance notice (60 days) notices. S1 stated there has not been any new rent rate increases since the introduction of the new management company on 07/01/2025. Hospitality. Based on information obtained, the allegations are 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. Exit interview conducted, and a copy of this report provided to Justin Zackzewski, Director of Hospitality.

...continued from LIC9099. Allegations: UNSUBSTANTIATED Staff working while under the influence of alcohol. The reporting party remained anonymous; however, S1 and S2 thinks they know who initiated the complaint. LPA reviewed personnel records for disciplinary actions against staff from February 2025 - May 2025, no records revealed any misuse of alcohol while staff were on duty. On 02/25/25, S2 stated that S3 was being mean towards S1; it wasn't right. S3 was looking for S1 with a disgusting look (teasing). S1 stated that the complaint has no merit and S1 is not comfortable being with S3. S3 stated that he/she did not want to mention who told him/her that S1 smells like alcohol because S3 doesn’t want to get them in trouble. S1 stated that S3 said he/she smelled tequila. S2, S3, S6, R1, R2, and R3’s interviews did not reveal any witnessing or knowledge of any staff working while under the influence of alcohol. Staff disrespectful to residents and residents' families. R1 stated that everything is okay at the facility. R1 said he/she had not met or talked to S1 yet, but R1 has seen S1. R2 thinks he/she is getting what R2 needs, but has not met S1, and has lived at the facility for over 2 years. R3 said he/she has only talked or interacted with S7, and “S7 is realistic about what’s going on.” R3 has not met S2 or S1. Based on information obtained, the allegations are 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. Exit interview conducted, and a copy of this report provided to Justin Zackzewski, Director of Hospitality.

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 05/20/2025 around 9:15 AM, Licensing Program Analysts (LPA) L. Holmes arrived unannounced to conduct a proof of correction (POC) inspection. LPA met with Justin Zackzewski, Director of Hospitality and explained the purpose of the visit. Facility has the following deficiencies that were not cleared, and deficiencies were issued on 05/02/2025 from California Code of Regulations, Title 22 : - 87303 (b)(3): Licensee/ED to assess HVAC system, thermostat, and make repairs. Consult R1 about temperature range, provide proof of training with signatures, and invoices by POC date. - 1569.80 (b) Licensee/ED to inform R1's physician by written communication, provide proof of notice to CCLD, review regulation, and certify with signatures by POC. - 87468.2 (a)(2) Licensee/ED to review regulation and ensure that all residents records are presented and maintained with confidentiality. Provide in-service training for Care Staff, and signatures as proof. Civil penalties of $1100.00 are assessed for the period of 05/10/25 to 05/20/25 for failure to correct each above deficiency. Total civil penalties in the amount of $3300 are being assessed today. Facility is subject to ongoing civil penalties until deficiencies are corrected. Exit interview conducted. A copy of this report, civil penalties, and appeal rights provided.

...continued from LIC9099. Allegation: Substantiated Staff did not ensure residents thermostat was working properly Interviews with staff indicated the following: On 04/22/25, S2 stated. “One of the units on the roof didn't have Freon. It affected about 3 apartments; it was the AC and the heater, and this was to regulate the temperature. On the third floor there were maybe 2 apartments affected.” S4 stated “I will admit that the temperature has been an ongoing issue and that's been about two months. S3 stated that he/she performed periodic checks in R1’s room, and that the centralized system that regulates the temperature did not indicate any fault in R1’s apartment. LPA and S4 attempted to adjust the temperature on R1’s thermostat below 77 degrees F. and thermostat continually defaulted to 77 degrees F. LPA immediately placed a service request with the concierge. On 04/30/25 S1 stated. “The HVAC system has been fixed for well over a week, we have the tech coming out tomorrow for an unrelated project and I will have him stop by the unit once again.” LPA, S3 and S2 attempted to adjust the thermostat to 80 degrees F. LPA returned after an hour and the thermostat increased 1 degree from 78 to 79, but not 80. In addition, R1’s filter needs to be cleaned. Allegation: Substantiated Staff did not do a proper reassessment of residents care needs A Functional Evaluation was conduct for R1 on 10/17/25 by S2, and on 04/08/25 by S3. The 04/08/25 evaluation was initiated by S1 and R1 disagrees. The records reviewed by LPA and R1 revealed that S1, S2 and S3 did not include written record from the facility informing R1’s regular physician of the results of either functional evaluation for R1’s care needs. 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, and a copy of this report provided to Tsedey Mekonnen, Concierge.

...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. Staff allowed a resident to be soiled while in care W2 reported he/she arrived at the facility for his/her shift t and found R1 was left in soiled clothing and sheets with feces. W2 report the incident to W1. W2 stated he/she saw S5, and S6 that morning and was not sure why no one had responded to R1. W2 stated all the caregivers or housekeeping would have had to do is put R1 in the shower. It was about 9:00 AM when S10 was passing the medications. It took S10 about 3 hours to comeback regarding R1’s ingrown toenails. W2 asked S10 to please give R1 the Imodium A-D for diarrhea; R1 was having stomach issues. W2 stated. “The one thing that is wrong with the facility for sure is that there are no nurses.” S4 was not at the facility that day. According to W2, S10 finally called someone, and it was about 1:00 – 2:00 PM before R1 received the medication to relieve the diarrhea. LPA interviewed W3, and W4, and both stated that they have had incontinence concerns with the facility also. Staff mishandled a resident's medication while in care Records requested and interviews with W1 and W2 revealed that R1 is prescribed Imodium A-D. The Medication Sheet has two separate and different entries for R1’s Centrally Stored Medication; neither were notated as being administered for 12/2024. LPA reviewed R1’s Physician’s Report (LIC602); LPA reviewed R1’s Progress Notes and there was not any notation or refusal for the month 12/2024. Interviews with W1 and W2 reveal that R1 had an incident with diarrhea and vomiting on or around 12/16/24. S10 administered Imodium (A-D); however, the time, date and dosage is unknown and was not recorded on any day of R1's Medication Sheet for the month 12/2024. Based on LPA’s observations, 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 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 04/01/2026 at 10:30 AM, Licensing Program Analyst (LPA) T. Syess-Gibson conducted an unannounced Case Management visit regarding information provided pertaining to a resident committing suicide at the facility. The facility sent in a death report on 03/11/2026 and spoke with CCL office support on 03/10/2026 to advise of incident. LPA met with Executive Director (ED), Quaid Holder, and Director of memory care, Maureen Lee, and explained the purpose of the visit. Death Report (LIC624A) indicated that Resident 1 (R1) was in shower with shower hose around neck. Staff performed CPR until Paramedics arrived. Paramedics pronounced R1 as deceased at 11:58am. During the visit, LPA reviewed, facility roster, death report, R1's service plan, physician report, face cover sheet, identification and emergency notification, and service plan. LPA may return at a later time. No deficiencies cited. Exit interview conducted and a copy of this report provided.

...continued from LIC9099. Staff did not provide resident medication as requested. LPA reviewed a sample of two dates from R1’s Medication Notes, and Progress Notes before around the alleged time frame that R1’s medication was mishandled during December 2024. R1 is prescribed Milk of Magnesia (PRN) for nighttime. On 12/18/24, the Medication Sheet revealed that S11 administered PRN at 03:24 AM; progress notes revealed that PRN was requested by R1 at 9:00 PM but not administer by S8 which is noted on the Medication Sheet. On 12/19/24, S12 administered PRN at 08:53 PM and noted that R1 requested PRN again at 11:00 PM. Records do not reflect that there was any medication administered in error, and R1 was administered his/her prescribed Metamucil for the entire month of December as prescribed except when R1 refused on 12/18/2024. R1 and W1 could not identify specific PRNs and/or prescribed medications that weren’t administered when requested according to the physician’s orders. Based on LPA’s observations, interviews and records reviewed, the preponderance of evidence standard has not been met; therefore, the above allegation is UNSUBSTANTIATED . Exit interview conducted and a 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 09/17/2024 and conducted by Evaluator Lisha Holmes Staff left residents in soiled diapers for an extended period of time resulting in injury Staff sleeping during work hours Staff screamed at resident On 1/14/2025 around 10:00 AM, Licensing Program Analyst (LPA) L. Holmes and Licensing Program Manager (LPM) Yvonne Flores-Larios arrived unannounced to deliver the findings for the above allegations. LPA and LPM met with Douglas Blake, Interim Executive Director (ED) and Executive Director (ED) Annemarie Domizio and explained the purpose for the visit. During the course of the investigation and visits, LPA and LPM requested an updated staff and resident roster, reviewed staff schedules and training records, and requested documentation for Staff #7 (S7's). Personnel job descriptions & specifications, and contact information for staff. LPA and LPM requested residents' (R1, R2, R3, R4, R5) LIC602's, ID/Emergency Contact Information, Progress Notes and Centrally Store Medication and Destruction Reports. LPA and LPM interviewed staff (ED, S1, S2, S3, S4, S5, S16, S17, S18) and Witnesses (W2, W3, W4). Continued on 9099C... SUPERVISORS NAME : Yvonne Flores-Larios LICENSING EVALUATOR NAME : Lisha Holmes LICENSING EVALUATOR SIGNATURE : DATE: 01/14/2025 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 ...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... SUPERVISORS NAME : Yvonne Flores-Larios LICENSING EVALUATOR NAME : Lisha Holmes LICENSING EVALUATOR SIGNATURE : DATE: 01/14/2025 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 ...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. SUPERVISORS NAME : Yvonne Flores-Larios LICENSING EVALUATOR NAME : Lisha Holmes LICENSING EVALUATOR SIGNATURE : DATE: 01/14/2025 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 This is an official report of an unannounced visit/investigation of a complaint received in our office on 09/17/2024 and conducted by Evaluator Lisha Holmes On 1/14/2025 around 10:00 AM, Licensing Program Analyst (LPA) L. Holmes and Licensing Program Manager (LPM) Yvonne Flores-Larios arrived unannounced to deliver the findings for the above allegations. LPA and LPM met with Douglas Blake, Interim Executive Director (IED) and Executive Director (ED) Annemarie Domizio and explained the purpose for the visit. During the course of the investigation and visits, LPA and LPM requested an updated staff and resident roster, reviewed staff schdeules and training records, and requested staff record for S7. Personnel job descriptions, job specifications, and contact information for staff. LPA and LPM requested residents' (R1, R2, R3, R4, R5) LIC602's, ID/Emergency Contact Information, Progress Notes and Centrally Store Medication and Destruction Reports. LPA and LPM interviewed staff (ED, S1, S2, S3, S4, S5, S16, S17, S18) and Witnesses (W2, W3, W4). Continued on 9099C... SUPERVISORS NAME : Yvonne Flores-Larios LICENSING EVALUATOR NAME : Lisha Holmes LICENSING EVALUATOR SIGNATURE : DATE: 01/14/2025 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 ...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. SUPERVISORS NAME : Yvonne Flores-Larios LICENSING EVALUATOR NAME : Lisha Holmes LICENSING EVALUATOR SIGNATURE : DATE: 01/14/2025 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 Personnel Requirements-General 87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. -This requirement is not met as evidenced by: Licensee and administrator (ADM) to review all residents appraisals and care plans to ensure there is sufficient number of staff to provide adequate care and supervision to all residents. ADM to provide R2, R3, R4, R5 and their responsible parties a current incontin

...amendment continued from LIC9099. For the above allegation, W1 reported that on 12/23/24 he/she learned from about four (4) care staff that the residents were being served cereal with milk that had water inside of the milk. S2 stated that a new chef has been hired, and in the interim S2 is assisting the kitchen and has made purchases specifically for milk on 12/23/24 from Mi Tierra Foods located adjacent to the facility, the prior purchase was from the vendor Sysco-San Francisco on 12/21/24, and the following purchases were made 12/28/24 and 01/02/24. While touring the facility there was a half of a gallon milk present; however, the delivery arrived during the visit just after the purchase from Mi Tierra Foods around 11:00 AM on 01/02/24. S6 stated that the milk was probably low-fat. S7 stated that the facility does not do that, does serve milk with have the cream, whole milk or 2% fat. S8 stated the milk is probably 2% fat. S4 and S5 said they've never heard of the milk being watered down. S1 stated that the local Ombudsman toured the facility on 12/31/24 to view the dry and cold storage goods without any further recommendations. To date the facility has a sufficient variety, quality and quantity of perishable and non-perishable foods on the premises to meet the dietary needs of the residents. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the allegation; therefore, it is UNSUBSTANTIATED. No citations issued during visit. Exit interview conducted and a copy of this report provided to Claudia Redditt, Director of Business Administration .

On 05/02/2025 around 11:00 AM, Licensing Program Analyst (LPA) L. Holmes conducted a case management as result of an unannounced initial 10-day complaint dated 04/30/2025 #15-AS-20250430171112. LPA met with Justin Zackzewski, Director of Hospitality. LPA and S1 discussed the above complaint. S1 to provide LPA with emails and/or correspondences regarding R1's admission at the facility. LPA referenced Title 22, Division 6 Chapter 8 Article 06. Background Check and Title 22, Division 6 Chapter 8 Article 07. Personnel 87412 Personnel Records. This conversation was related to S1, S2, S3 and all other employees that are responsible for administration, direct supervision of staff, and care for residents. Exit interview conducted, and a copy of this report provided to Tsedey Mekonnen, Concierge.

... amendment continued from LIC9099. For the above allegation, R1 stated that R2 was verbally harassing him/her multiple times and just prior to the complaint is when R2 used a curse word towards R1. R1 could not identify any witnesses, R1 stated that the incident was reported to S1 and S2. S1 stated that R1 did not report that specific incident and S1 would have recalled something like that; R2 does have occasional outburst which may be due to a medical condition, but never anything abusive. S1 stated that he/she spoke to R1 regarding R2 allegedly glaring at R1. S1 suggested R1 and R2 sitting away from each other and/or repositioning R1's chair for avoidance. R1 requested LPA to allow him/her to remain anonymous with R2; therefore, LPA did not interview R2. S2 stated that there had been discussions on 01/02/24 about R1 and other residents having disagreements, and R1's disruptive behavior; R1 never reported the specific incident nor had S2 seen any verbal harassment. S3 did not remember ANYTHING reported like the allegation. S3 stated that he/she wouldn't have had a problem saying something or approaching R2. S4 stated that the allegation is not surprising because R1 will go behind the bistro bar even though R1 is not suppose enter the area, and R1 does not want R2 or S4 to say anything about it him/her. S4 stated that R1 goes out of his/her way to provoke R2, and R1 is taking things out of proportion. W1 has visited the facility 2-3 times weekly over the last two (2) years and has never witnessed any verbal harassment. S1 and S2 have agreed to speak with R1 and R2 individually about the facility's expectations. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the allegation; therefore, it is UNSUBSTANTIATED. No citations issued during visit. Exit interview conducted and a copy of this report provided to Claudia Redditt, Director of Business Administration

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 08/15/2024 and conducted by Evaluator Lisha Holmes 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 On 11/20/2024 around 09:45 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to deliver the complaint findings for the above allegations. LPA met with Mary Anne Watral, Operations Specialist (OP) and Interim-Douglas Blake, Executive Director (ED) and explained the purpose of the visit. During the course of the investigation and visit, LPA toured the facility conducted interviews with ED, OP, Staff, and Witness #1. LPA requested R1's file including, but not limited to the following documents: Current Personnel Report (LIC 500), Resident Roster, copies of R1's Centrally Stored Medication Log, medication records, housekeeping schedule, blood sugar record, LIC602, and Admission Agreement. Continued in LIC9099C... SUPERVISORS NAME : Yvonne Flores-Larios LICENSING EVALUATOR NAME : Lisha Holmes LICENSING EVALUATOR SIGNATURE : DATE: 11/19/2024 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 ...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... SUPERVISORS NAME : Yvonne Flores-Larios LICENSING EVALUATOR NAME : Lisha Holmes LICENSING EVALUATOR SIGNATURE : DATE: 11/20/2024 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 ...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... SUPERVISORS NAME : Yvonne Flores-Larios LICENSING EVALUATOR NAME : Lisha Holmes LICENSING EVALUATOR SIGNATURE : DATE: 11/20/2024 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 ...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. SUPERVISORS NAME : Yvonne Flores-Larios LICENSING EVALUATOR NAME : Lisha Holmes LICENSING EVALUATOR SIGNATURE : DATE: 11/20/2024 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 This is an official report of an unannounced visit/investigation of a complaint received in our office on 08/15/2024 and conducted by Evaluator Lisha Holmes Staff did not ensure resident received adequate laundry services Staff did not ensure resident received personal mail parcels Staff did not ensure residents dietary care plan was properly followed On 11/20/2024 around 09:45 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to deliver the complaint findings for the above allegations. LPA met with Mary Anne Watral, Operations Specialist (OP) and Douglas Blake, Interim-Executive Director (ED) and explained the purpose of the visit. During the course of the investigation and visit, LPA toured the facility conducted interviews with ED, OP, Staff and Witness #1. LPA requested R1's file including, but not limited to the following documents: Current Personnel Report (LIC 500), Resident Roster, copies of R1's Centrally Stored Medication Log, medication records, housekeeping schedule, blood sugar record, LIC602, and Admission Agreement. Continued in LIC9099C... SUPERVISORS NAME : Yvonne Flores-Larios LICENSING EVALUATOR NAME : Lisha Holmes LICENSING EVALUATOR SIGNATURE : DATE: 11/20/2024 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 ...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

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 LIC9099. Allegations: UNSUBSTANTIATED Staff did not provide resident's medication as prescribed Staff did not monitor resident's blood pressure to ensure it was safe for resident to take medication Staff are not adequately trained to meet resident needs LPA interviewed R1, and R1 stated that he/she was concerned that S1 hadn't been fired. S1 never apologized for doing anything wrong and is still passing medications. On 09/09/24, R1 received a doctor's order to administer his/her own medication, and S2 performed a Medication Self Administration evaluation on 10/02/24 after R1 presented S2 with the physician's note. The license was cited on complaint 15-AS-20240830161136 received 08/30/24 and provided proof of corrections for the above allegations . Allegation: UNSUBSTANTIATED Staff are billing resident for services not being rendered. ED stated that he/she was unaware of a billing issue or dispute related to R1. ED had not received any written or oral communications from R1 regarding billing. ED provided LPA with proof of R1's transaction history for 10/2024 that shows a credit for services, and explained it was effective 10/02/2024 when S2 performed a Medication Self Administration evaluation for R1. ED will provide an explanation and notification to R1 on or before 11/04/2024. Based on information obtained, 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 deficiency cited, exit interview conducted, a copy of this report and appeal rights provided to Douglas Blake, ED.

On 10/24/2024 around 09:30 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a needs further investigation, open a complaint and completed a case management regarding Resident #1 (R1). LPA met with Douglas Blake, Executive Director (ED) and explained the purpose for the visit. During the course of the investigation and visit, LPA conducted an interview with ED and confirmed that R1's reappraisal was due on 09/10/24 as a result of a case management on 09/03/24. A Functional Evaluation was not completed until 10/02/24. 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, a copy of this report, and appeal rights provided to ED.

...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 09/16/2024 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.

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 12/12/2024 around 04:00 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a case management for an Unusual Incident Report received regarding Resident #1 (R1). LPA met with Mary Anne Watral, Operations Specialist (OS) LPA interviewed OP and S2. LPA requested and reviewed R1's Physician's Report (LIC602), Functional Evaluation, Resident Appraisal needs and UIR dated 12/11/24. LPA confirmed that R1 can leave the facility unassisted. R1 was locked out of the facility, was able to contact his/her daughter from a passerby, and was returned to the facility on 12/04/24. As a result of R1's confusion, R1 to follow-up with the Primary Care Physician on 12/13/24. The facility has contracted an agency (RTF) to install a keyless entry pad along with a notification system at the front entrance. LPA and OP discussed recent incidents with Residents (R1, R2, R3, R4); incident reports will follow. OP self reported that an internal investigation is underway for S1 and R4. All required parties have been notified of the incidents. No deficiencies cited, exit interview conducted, and a copy of this report provided to OP.

...continued from LIC9099. LPA had received written notice from the facility that the former ED has resigned and was aware that there would be an interim staff (S2, #6066818740 exp: 01/22/25) as the administrator for the allegation the facility does not have an administrator on the premises; therefore the allegation was unsubstantiated. Exit interview conducted. A copy of this report and appeal rights were provided to 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.

...Report Continued from LIC9099 Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove it; therefore, the allegation is UNSUBSTANTIATED. No citations issued during visit. Exit interview conducted with ED. Appeal Rights and a 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 08/30/2023 and conducted by Evaluator Alicia Delmundo -Staff allow a resident to be in soiled clothing for extended periods of time. -Staff do not properly maintain resident's bedroom. -Staff do not meet a resident's incontinence needs while in care. -Staff did not safeguard resident's personal belongings. -Staff do not properly maintain the facility grounds. -Staff inappropriately removed a resident's hygiene products while in care. -Staff did not provide adequate supervision to a resident while in care. At 11:40 a.m. on this day, 4/25/24 , Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings for the above allegations. LPA met with Director of Health and Wellness LaTiana James, and informed the reason for visit. LPA called and left message on Executive Director Robert Coe's voicemail. On 9/05/23, LPA Gregory Clark conducted the 10-day complaint visit. On 3/05/24, Licensing Program Manager (LPM) Jeremy Fong conducted a subsequent investigation. During the course of investigation, LPA Clark obtained copies of resident roster and staff schedule. LPA Clark and LPM Fong toured the facility and obtained copies of residents including but not limited to the following documents: Admission Agreement; Identification and Emergency Contact Information; LIC602A Physician's Report (MD Report); Needs and Services Plan; incident reports. LPM Fong also conducted interviews. ......continued on 9099C (page 2) SUPERVISORS NAME : Bennett Fong LICENSING EVALUATOR NAME : Alicia Delmundo LICENSING EVALUATOR SIGNATURE : DATE: 04/25/2024 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 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) SUPERVISORS NAME : Bennett Fong LICENSING EVALUATOR NAME : Alicia Delmundo LICENSING EVALUATOR SIGNATURE : DATE: 04/25/2024 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 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) SUPERVISORS NAME : Bennett Fong LICENSING EVALUATOR NAME : Alicia Delmundo LICENSING EVALUATOR SIGNATURE : DATE: 04/25/2024 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 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. SUPERVISORS NAME : Bennett Fong LICENSING EVALUATOR NAME : Alicia Delmundo LICENSING EVALUATOR SIGNATURE : DATE: 04/25/2024 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 This is an official report of an unannounced visit/investigation of a complaint received in our office on 08/30/2023 and conducted by Evaluator Alicia Delmundo At 11:40 a.m. on this day, 4/25/24 , Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings for the above allegations. LPA met with Director of Health and Wellness, and informed the reason for visit. LPA called and left message on Executive Dire ctor Robert Coe's voicemail. On 9/05/23, LPA Gregory Clark conducted the 10-day complaint visit. On 3/05/24, Licensing Program Manager (LPM) Jeremy Fong conducted a subsequent investigation. During the course of investigation, LPA Clark obtained copies of resident roster and staff schedule. LPA Clark and LPM Fong toured the facility. LPM Fong also conducted interviews. ......continued on 9099C (page 2) SUPERVISORS NAME : Bennett Fong LICENSING EVALUATOR NAME : Alicia Delmundo LICENSING EVALUATOR SIGNATURE : DATE: 04/25/2024 I acknowledge receipt of this form and understand my licensing appeal rights as exp

...Report Continued from LIC9099 The complaint alleges that staff did not provide resident's POA with requested documents. Review of R1’s Admissions Agreement dated 11/18/2022 by the LPAs revealed that it was missing the Resident Handbook and that communications by the facility with R1’s POA did not provide the requested documents. The preponderance of the evidence standard has been met, and the allegation is SUBSTANTIATED. Deficiency is cited under the California Health and Safety Code listed on LIC9099-D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted with ED Coe. Appeal Rights and a copy of this report provided via email.

...Report Continued from LIC9099 The complaint alleges that staff are not providing daily activities for residents. On 3/28/2024, the LPAs interviewed the ED and Director of Health and Wellness Tea James, reviewed the facility’s March 2024 Activities calendars for Assisted Living and Memory Support, and observed 20 residents in Memory Support interacting with 10 Staff Members. Based on these interviews and observations, the LPAs concluded that daily activities are being provided. Although the allegations may have happened, or are valid, there is not a preponderance of evidence to prove them; therefore, the allegations are UNSUBSTANTIATED. Exit interview conducted with ED Coe and Director James. Appeal Rights and a copy of this report provided via email.

On 07/30/24 around 10:30 AM, L. Holmes Licensing Program Analyst (LPA) arrived unannounced to conduct a case management for an "Elopement" of Resident #1 (R1). LPA met with Robert Coe, Executive Director (ED) and explained the purpose of the visit. On 07/29/24, ED reported that there had been an elopement of R1 on that same day, an Unusual Incident Report (UIR) would follow, R1's son returned R1 to the facility, and R1 now resides in Memory Support. R1 was admitted to the Assisted Living (AL) unit of the facility on 07/26/24. R1’s family was to assist with R1 transitioning from home to the facility throughout the weekend. On 07/29/24, R1 left the facility walking his/her dog but the facility staff was unaware that R1 was alone. While out of the facility in the community, R1 started feeling faint and asked a passerby to use their phone. The Berkeley Fire Department (BFD) was contacted and in turn BFD alerted W1 and the facility that R1 would be transported to Alta Bates Hospital in Berkeley, CA for further observation. W1 contacted ED regarding R1’s assessment and returned R1 to the facility the same day. Staff (S2) reassessed R1, completed a new functional evaluation that now includes wandering, exit seeking behaviors, MCI and a terminal illness that qualifies R1 for Memory Support that further includes photos of new resident's at the front desk, photos at the assisted living and memory support units, photos on the E-MAR and on the file face sheets. No deficiencies cited. Exit interview conducted and a copy of this report provided to Robert Coe, Executive Director.

On 05/25/23 around 04:00 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced and conducted a post licensing visit. LPA met with Andrew Badoud, Executive Director (ED) and Claudia Lopes, Director of Business Administration and explained the purpose of the visit. The staff members interviewed were fingerprint cleared and associated to this facility. There was sufficient lighting throughout the facility. The facility offers assisted living and memory care. There were no bodies of water present in or around the facility. Bathrooms were equipped with the required hygiene items. Common areas are equipped with adequate furniture for the residents. The salon is in service and a pianist was performing for staff and residents. Fire extinguishers were present throughout the facility, observed full, and ADM to add new tag to portable fire extinguishers. Smoke detectors and carbon monoxide detectors were located throughout the facility and operational. There is a Med. Tech./Nurses Station on site with first aid equipment present. Emergency Disaster Plan is on file and the facility was maintained at a comfortable temperature. No deficiencies cited during this post-licensing inspection. Exit interview conducted and a copy of this report was provided Andrew Badoud, Executive Director

On 08/22/2022 at 01:20 PM, Licensing Program Analysts (LPAs) L. Holmes and Meenakshi Malik arrived announced to conduct a Pre-licensing Inspection. While at the facility for Prelicensing, LPAs completed a Component III presentation with Andrew Badoud, Executive Director (ED), Nicole Dockson, Vice President (VP), and Angelica Gonzalez-Gillam, Director of Health and Wellness. LPAs discussed the COVID-19 infection control requirements, the importance of attending the informational calls, understanding the updated guidelines and printing the provider information notices (PINS) for clients, authorized representatives and staff so that the facility maintains awareness and updates for compliancy with the Title 22 regulations. -Component III completed. Exit interview conducted and a copy of this report provided to Andrew Badoud, Executive Director.

On 12/5/22 at 2:40PM, Licensing Program Analyst (LPA) C. Lin conducted an unannounced case management visit as a result of receiving resident from Grand Lake Gardens (GLG) and check on resident. LPA met with Administrator and explained the purpose of the visit. A total of 1 resident from GLG is currently living in Elegance Berkeley. During visit, LPA attempted to visit resident however the resident was out with family. Supplies were adequate and staffing is stable. There was no imminent health/safety concerns on today's date. Exit interview conducted with Administrator and a copy of this report provided.

On 08/22/2022 at 10:00 AM, Licensing Program Analysts (LPAs) L. Holmes and Meenakshi Malik arrived announced to conduct a Pre-licensing Inspection. Upon arrival, LPAs were greeted by Andrew Badoud, Executive Director (ED). The facility is approved for a capacity of 120. There was a screening station with a touchless thermometer, COVID-19 screening forms and signage, masks, and a dedicated receptionist desk with two staff. LPAs toured facility with ED, Nicole Dockson, Vice President of Operations-West (VP), and Angelica Gonzalez-Gillam, Director of Health and Wellness. LPAs toured facility including, but not limited to the common areas, activity/games rooms, bathrooms, salon, bistro, kitchen, sensory room, courtyards/patio, parking structure and offices. The rooms were equipped with the proper furniture and enough space for everyone to social distance. Lighting is sufficient throughout the facility. The Bathrooms were equipped with soap, covered garbage cans, and paper towels.Each resident has their own apartment or shared apartment. There was a sufficient supply of 7-day non-perishable foods. The room temperature was maintained at 70 degrees F and hot water temperature was maintained at 103 degrees F. First-aid kit was observed complete. Smoke detectors and carbon monoxide were operational and monitored by the Fire Department. Fire extinguisher was last serviced on 02/24/2022. August activity calendars were provided and Component III reviewed and completed with ED, VP and Director of Health and Wellness. CORRECTIONS OBSERVED: - Water temperature needs to be maintained between 105-120 degrees F. - All staff needs to be associated to the facility prior to working at the facility. LPAs observed that facility is not ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAU. Additional requirements may still be required. Exit interview conducted and a copy of this report provided to Andrew Badoud, Executive Director.