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On December 10, 2025 Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. Upon entry, LPA met with Business Office Manager, Arno Manteiro and Resident Care Director, Anne Aquino and LPA explained the purpose of today's visit. The Vice President of Operations, Phil Altman arrived and assisted with the inspection. LPA toured the facility with Resident Care Director and LPA observed the common area with a large dining room, activity rooms, kitchen, medication rooms on different floors, resident rooms, laundry rooms, etc. The memory care unit is located on the 3rd floor and doors are security by the wander guard system. Medications are locked in the medication/work rooms on the 2nd, 3rd, 4th and 5th floor and inaccessible to residents in care. Lighting is sufficient for comfort. Chemicals, toxins, and sharps objects were observed to be locked and inaccessible to residents. 2 days of perishables and 7 days of nonperishable foods were observed for the residents. Fire drill records observed to be sufficient. 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 Hot water temperature in the resident's bathrooms and kitchen were measured at 108- 117 degrees F. A review of (6) resident files was conducted and noted on the LIC 858. A review of (5) staff files was conducted and noted on the LIC 859. No deficiencies cited today. This report is reviewed and discussed with the VP of Operations. A copy is provided.

As part of the investigation, LPA interviewed staff #2 (S2) who was training S1 on the day of the incident and stated that S1 was in training, and both stayed to ensure that R1 took all the medications then they left the room. After the investigation, this allegation is unsubstantiated because there was no mistake made with R1’s medication administration. It was an accident that R1 almost dropped a pill while taking his/her pills but both staff members followed R1’s evaluation and plan and stayed with R1 to ensure R1 took all the medications before exiting the room as this was observed by the responsible party. Regarding to the allegation of staff did not ensure resident’s medications were refilled in a timely manner, the reporting party stated that on March 30, 2025, the responsible party received a call from the facility reporting that two of R1's medications were running low but the facility had enough to last for a few more days. On the next day (March 31, 2025), the responsible party received a from R1 at 7:01pm and stated that he/she did not take one of the medications that was running low. Subsequently, the responsible party called the facility and verified the medication ran out and delivered the medication that night. The responsible party also stated that the facility was supposed provide notification when R1’s medication has less than two weeks supply. According to the Memory Care Director, the facility has two types of medication refill systems for the residents. When the facility is managing the medications, the facility is responsible to ensure all the refills are done and when the resident or their responsible party is managing the medications, they will be the one to keep track of all the refills and the facility will make a courtesy call 2 weeks before the medications run out. The Memory Care Director stated that R1’s medication is managed by R1’s responsible party and S2 conducted the courtesy call 2 weeks prior to the medications were running low. LPA interviewed S2 who stated that he/she conducted a courtesy call 2 weeks in advance to the responsible party informing them that R1's medication was running low. 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 Based on the documents provided by the facility, under Resident Evaluation, it indicated that R1 does not receive medication administration assistance from the facility instead, resident or family manages all aspects of the refills, including ordering and delivery of medications. Based on 24 hours shift report, it was documented by staff that on 3/30/2025, a courtesy call was made to R1’s family for the refills. After the investigation, this allegation is deemed to be unsubstantiated because R1’s family is managing R1’s medication and courtesy calls were made for the refills. Although the above allegation 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 allegation is UNSUBSTANTIATED. This report is reviewed and discussed with the memory care director. A copy is provided.

Based on R1's evaluation/service needs and plan, it indicated that R1 did not required assistance for grooming, eating, walking, dressing, etc. After the investigation, this allegation is deemed to be unsubstantiated as there was no proof indicating the duration of R1 on the floor and there was no document indicating there was an agreement between the facility and the responsible party that the safety checks shall be completed at the beginning of each shift. Regarding to the allegation of - staff did not keep the residents authorized person informed regarding the resident's hospitalization, the reporting party stated that the facility informed him/her that R1 was transferred to the South San Francisco Kaiser due to a fall and when he/she called South San Francisco Kaiser and another Kaiser, he/she was told that R1 was not there. Subsequently, the responsible party called the facility and spoke to staff #1 (S1) who stated that he/she would get more information and call the responsible party back. However, S1 never called the responsible party instead staff #2(S2) called the responsible and by that time, the responsible party had already got a call from the hospital where R1 was transferred to. As part of the investigation, LPA interviewed the memory care director, and S1. According to the memory care director, during the transfer, the paramedics informed S1 that R1 would be transferred to Kaiser South San Francisco and the facility was not aware that R1 was being brought to another hospital until they were informed by the responsible party. The memory care director stated that S1 did not call the responsible party back because the responsible party called S1 when the shift was ending, therefore, S1 endorsed it to the incoming shift med tech (S2) to continue to follow up and called the responsible party back when additional information was obtained. LPA interviewed S1 who also reported that he/she was told by the paramedics that R1 would be transferred to Kaiser South San Francisco and stated that when the responsible party called, the shift was ending so he/she endorsed it to the incoming staff to follow up. 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 After the investigation, this allegation is deemed to be unsubstantiated as the facility was unaware of R1's final destination which was decided by the paramedics after R1 had left the facility. However, during the investigation, the director acknowledged that staff did not get R1's vitals and report the result back to the responsible party as requested by the responsible party. This observation will be cited on Case Management visit under LIC809 and LIC809D. Although the above allegation 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 allegation is UNSUBSTANTIATED. This report is reviewed and discussed with the memory care director. A copy is provided.

On December 3, 2024 Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. Upon entry, LPA met with Business Office Manager, Arno Manteiro and Memory Care Director, Anne Aquino and LPA explained the purpose of today's visit. The administrator arrived shortly thereafter. Memory Care Director provided a tour of the common area with a large dining room, activity rooms, kitchen, medication rooms, resident rooms, laundry rooms, etc. The memory care unit is located on the 3rd floor and all the residents wear a wander guard device/pendent that emit an audible alert when they are in close proximity of the door to prevent residents from wandering off the unit. Medications are locked in the medication/work rooms on the 2nd, 3rd, 4th and 5th floor and inaccessible to residents in care. Lighting is sufficient for comfort. Chemicals, toxins, and sharps objects were observed to be unlocked and inaccessible to residents. 2 days of perishables and 7 days of nonperishable foods were observed for the residents. Fire extinguishers throughout the facility were last serviced on 7/31/2024. Fire drill records observed to be sufficient. Hot water temperature in the resident's bathrooms and kitchen were measured at 105- 111 degrees F. 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 A review of (5) resident files was conducted and noted on the LIC 858. A review of (5) staff files was conducted and noted on the LIC 859. The following updated forms/information are requested to be submitted to CCLD BY 12/6/2024: • LIC 500 Personnel Report • LIC 610E Emergency Disaster Plan (signed and dated) • Proof of current Liability Insurance - Administrator Certification No deficiencies cited today. This report is reviewed and discussed with the memory care director and the administrator. A copy is provided.

On December 3, 2024 Licensing Program Analyst (LPA) Murial Han conducted an unannounced Case Management visit to follow up on an incident that was reported by the facility. Upon entry, LPA met with Business Office Manager, Arno Manteiro and Memory Care Director, Anne Aquino and LPA explained the purpose of today's visit. The administrator, Sylvia Chu arrived shortly thereafter. On November 22, 2024, the facility reported resident #1 (R1) and resident #2 (R2)'s son reported to the facility that R1 was hit by (R2) in their apartment and R1 sustained an injury on the head. This incident was unwitnessed by facility staff. After the facility was informed of the incident, the facility worked with the responsible party and decided to moved R1 to another apartment and spoke to R2 who denied hitting R1 and reported that the head injury was due to a fall. The facility reported the incident to CCL, the Ombudsman and the Local Law Enforcement. During today's visit, LPA observed both residents; R1 appeared to be friendly and pleasant and R2 was sleeping in the new apartment. The Memory Care Director and the Administrator reported that both residents are doing well and they will continue to stay in separate apartments for now. No deficient is cited. This report is reviewed and discussed with the administrator and the memory care director. A copy is provided.

LPA Audrey Jeung toured facility and grounds, consisting of private and shared one and two bedroom apartments--all with private bathrooms--on 5 floors; assisted living units on floors 2, 4, 5, 6, and secured memory care only on 3rd floor. Two stairwells on 3rd floor are equipped with a 15 second delayed egress: one is tested and operates as required. The elevator that accesses the 3rd floor is secured with a Wanderguard system; memory care residents wear Wanderguard pendants that emit an audible alert when they are in close proximity to elevator. The facility accommodates non-ambulatory and hospice residents. Rooms are equipped with emergency call systems, which can be activated from bathrooms and bedrooms. There is a large dining room, activity rooms, kitchen, medical clinic, beauty salon, fitness room, common areas, offices on the ground level. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is adequate. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Liquid soap and paper towels are available in public bathrooms. First-aid kit is inspected and complete. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Sylvia Chu is an RCFE administrator that oversees facility operations. Current RCFE administrator certificate is not available for review. The following updated licensing forms or information are requested to be submitted to CCLD BY 1/11/22: - Emergency Disaster Plan (LIC610E) - Personnel Report (LIC500) - Proof of current liability insurance No deficiencies of the CA Code of REgulations, Title 22 are cited today. See LIC9102 for Technical Advisiory Notes related to COVID-19 protocols.