Campbell Village

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced Case Management to conduct a Non-Compliance Plan Quarterly Visit and met with Administrator (ADM) Geralyn De Ocampo . LPA stated the purpose of the visit. The purpose of the visit is to ensure the facility is adhering to the Compliance Plan submitted to Community Care Licensing Division (CCLD) after an informal meeting held on October 22, 2024. LPA toured the facility inside and out with ADM. LPA observed all exits and passageways were free and clear of obstruction. LPA toured 5 resident rooms and did not observe any obstructions in the passageways. ADM tested all 5 delayed egress doors. LPA observed all 5 delayed egress doors were working properly in both memory care and assisted living when tested by ADM. LPA reviewed staff training such as, but not limited to: Understanding Dementia Behavior and Elopement, Operation of Delayed Egress doors completed on 1/15/2026 and 2/12/2026. The facility is adhering to the facility Compliance Plan. No deficiencies cited per California Code of Regulations, Title 22. An exit interview was conducted with Administrator (ADM) Geralyn De Ocampo and a copy of this report was provided.

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced Case Management to conduct a Non-Compliance Plan Quarterly Visit and met Memory Care Supervisor (MCS) Audie Ton-Od. LPA stated the purpose of the visit. MCS stated Administrator (ADM) Geralyn De Ocampo would be arriving shortly. ADM arrived at 9:45AM for the visit. The purpose of the visit is to ensure the facility is adhering to the Compliance Plan submitted to Community Care Licensing (CCL) after an informal meeting held on October 22, 2024. LPA toured the facility inside and out with MCS. LPA observed all exits and passageways were free and clear of obstruction. LPA toured 5 random resident rooms and did not observe any obstructions in the passageways. MCS tested all 5 delayed egress doors. LPA observed all 5 delayed egress doors were working properly and free from any obstructions in both memory care and assisted living when tested by MCS. LPA reviewed staff training such as, but not limited to: Dementia and Elopement completed on 9/26/2025, 10/30/2025, and 11/20/2025. The facility is adhering to the facility Compliance Plan. No deficiencies cited per California Code of Regulations, Title 22. An exit interview was conducted with (Administrator (ADM) Geralyn De Ocampo and a copy of this report was provided.

Licensing Program Analysts (LPAs) Marcella Tarin and Manuel Monter conducted an unannounced annual inspection and met with Administrator (ADM) Geralyn De Ocampo. LPAs stated the purpose of the visit. LPAs toured the interior and exterior of the facility with ADM to include the kitchen, resident rooms, dining room, bathrooms, back and front of the facility. All exit and passageways were free and clear of obstruction. LPAs toured the kitchen area and observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPAs observed the refrigerator temperature at 40 degrees F and Freezer at -5 degrees F. LPAs observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. The facility was equipped with smoke and carbon monoxide detectors. The smoke detectors were inspected by a third party vendor on 6/16/2025. Fire extinguishers were last serviced on 2/28/2025. LPAs reviewed the facility first aid kit, and it was observed to be complete. The facility emergency drill log was reviewed. The facility's last drill was on 8/14/2025. LPAs toured 10 random resident bedrooms. All 10 resident rooms have a bed, functioning lights, dresser/table, bedding and space for personal belongings Page 1 of 2 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 LPAs toured 4 resident bathrooms. All 4 bathrooms had hand soap, paper towels, functioning lights, and covered trash bins. LPAs measured water temperature with a range of 114 F to 116 F. LPAs reviewed 4 resident records. LPAs reviewed 4 resident’s Centrally Stored Medication and Destruction Records (CSMDR’s). LPAs reviewed 4 staff records. LPAs observed the facility carpets being replaced, and the facility dining room currently closed due to renovation. ADM states residents are provided meals in their room, or in the common areas. ADM stated the facility maintenance staff are overseeing while the construction process is ongoing. ADM states the construction crew uses the common bathroom in the hallway. No deficiencies were cited during today's visit per California Code of Regulations Title 22. An exit interview was conducted with Administrator Geralyn De Ocampo and a signed copy of this report was provided. Page 2 of 2 END OF REPORT

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced Case Management to conduct a Non-Compliance Plan Quarterly Visit and met Administrator (ADM) Geralyn De Ocampo. LPA stated the purpose of the visit. The purpose of the visit is to ensure the facility is adhering to the Compliance Plan submitted to Community Care Licensing (CCL) after an informal meeting held on October 22, 2024. LPA toured the facility inside and out with ADM. LPA observed all exits and passageways were free and clear of obstruction. LPA toured 5 random resident rooms and did not observe any obstructions in the passageways. ADM tested all 5 delayed egress doors. LPA observed all 5 delayed egress doors were working properly and free from any obstructions in both memory care and assisted living when tested by ADM. LPA reviewed staff training such as, but not limited to: Dementia and Elopement completed on 8/11/2025. LPA also reviewed staff training on Delayed Egress completed on 8/7/2025. The facility is adhering to the facility Compliance Plan. No deficiencies cited per California Code of Regulations, Title 22. An exit interview was conducted with ADM Geralyn De Ocampo and a copy of this report was provided.

On 02/14/2024 home health services were initiated and record states that R1 developed a stage three pressure injury. On 04/04/2024 R1 was discharged from receiving home health services because the pressure injury has healed. On 10/15/2024, R1s home health services were renewed and was diagnosed with stage three pressure injury on the right heel, and stage one pressure injury on the sacral region. On 12/11/2024, R1 was discharged from home health services due to progressing pressure injury and was placed under hospice care. Based on interview of R1, R1 stated he/she does not care to be turned due to pain when moving. R1 refuses the booties given by staff to protect his/her heels and does not allow staff to put the booties on. Based on document review, facility staff informs R1s physicians when R1 refuses to be repositioned to prevent pressure injury. R1 is receiving palliative care daily for R1s wound and repositioning. Based on interviews with 5 staff (S1 to S5). 5 Out of 5 staff revealed consistent statements that R1 refused to be repositioned and refused any care to help heal the pressure injury. S3 stated he/she explained to R1 that R1 needs to be repositioned based on R1s care plan. Based on interviews with 5 witnesses (W1 to W5). W1 stated R1s health condition contributed to R1s pressure injury to worsen and R1 has a long history of refusing care. W1 stated, R1 is visited and cared for 5 times a week. W2 did not provide additional information. W3 stated that R1 refused to be re-hospitalized and wanted to stay in bed and R1 was non-compliant with ADL which led to progression of R1s wounds. Based on interviews, document reviews and investigations, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation of neglect and lack of supervision causing R1 to develop pressure injury is UNSUBSTANTIATED, based on California Code of Regulation (CCR) Title 22. Page 2 of 3 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Staff Mismanaging Medication On 7/10/2025, LPA Tarin reviewed R1's Medication Administration Record (MAR) for January through April 2025. LPA did not observe discrepancies for medications administered to R1 for the months of January through April 2025. LPA interviewed 2 staff (S6 and S7). 2 out of 2 staff stated R1 did not have any medications missing or misplaced during the months of January to April 2025. Based on document review, LPA observed all medications orders documented, with no reports of missing or misplaced medication Based on interviews with 5 witnesses (W1 to W5). W1 stated the facility 'misplaced' R1's medication in February 2025. W2 to W5 did not provide additional information. Based on interviews, document reviews and investigations, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation of staff mismanaging R1's medication, and is UNSUBSTANTIATE D, based on California Code of Regulation (CCR) Title 22. No deficiencies are being cited during today's visit. An exit interview was conducted with ADM and a copy of this report was provided. Page 3 of 3. End of Report

Based on interviews, 13 Out of 13 Residents (R1 to R13) stated he/she has never observed or heard about staff mistreating residents. 13 residents state facility staff treat him/her well and have no concerns. Based on interviews, 5 Out of 5 Staff (S1 to S5) stated he/she has never observed or heard about residents being required to take showers together. 5 staff stated he/she has never observed or heard about staff mistreating residents. This agency has investigated the above allegations and we have found that the complaint was UNFOUNDED meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with Administrator Geralyn De Ocampo, and a copy of this report was provided.

LPAs interviewed Residents R1-R10. 9 Out of 10 residents (R2-R10) stated caregivers are providing assistance in a timely manner when resident’s request for assistance. R1 stated approximately 3 to 4 weeks ago he/she sustained a fall in the morning in his/her bathroom. R1 stated he/she was yelling for help for approximately 20 to 30 minutes until a caregiver arrived. During the visit LPAs tested pendant in Room #222. The facility responded to this pendant test in 17 minutes and 30 seconds. (LPAs observed resident in #223 exit his/her room and requested for water. LPAs observed caregiver leave the area to get the resident the requested water, the caregiver then responded to resident in Room #222). LPAs also tested pendant in Room #226. A caregiver responded in 2 minutes to the pendant call in Room #226. LPAs interviewed Care Coordinator (CC). CC stated the facility has an extra staff in the morning shift and the facility is not short staffed. CC stated he/she has no knowledge of R1 falling or R1 being hospitalization in the past two months. LPAs reviewed progress notes for R1 for the months of April 2025 and May 2025. There were no documented falls for R1. LPAs also reviewed R1s hospital visits/fax communication file, and there is no mention or documentation of R1 falling in April 2025 and May 2025. LPAs reviewed facility incident reports. There were not documented falls or hospitalization's for R1 in April 2025 and May 2025. Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegation is UNSUBSTANTIATED . An unsubstantiated findin g indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegation did or did not occur. No deficiencies cited during today's visit per California Code of Regulations Title 22. An exit interview was conducted with Care Coordinator (CC) Gregg Madriaga and signed copy of this report was provided. Page 2 Out Of 2. 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 LPAs interviewed Residents R1-R10. 8 out of 10 residents (R1-R5, R7, R9, and R10) stated the facility is providing transportation to residents for their appointments on Tuesdays and Thursdays. 2 Out of 10 residents (R6 and R8) stated they do not use facility transportation for his/her appointments. R1 stated the facility has been taking him/her to his/her appointments on Tuesdays and Thursday but stated he/she has missed appointments but does not know the dates of the appointments missed. LPAs interviewed Care Coordinator (CC). CC stated the facility has a transportation schedule for resident appointments on Tuesdays and Thursdays. CC stated if a resident has an appointment that is on Tuesday or Thursday and the facility is unable to meet a resident's transportation request, example too many appointments, the facility will pay for and provide additional transportation via private transportation service. CC stated that residents are aware that the facility provides transportation on Tuesdays and Thursdays (the facility prefers an advance weeks notice for appointments). CC stated he/she is not aware of any incidents of residents missing his/her appointments. LPAs reviewed transportation schedules for April 2025 and May 2025. After review, the facility is scheduling transportation for residents, including R1, on Tuesdays and Thursdays. Residents’ names, dates and appointment locations are noted on the transportation schedule. The Department has completed the investigation of the above allegation. Based on interviews conducted and records review, the Department has found that the above allegation is UNFOUNDED , meaning that the allegations were false, could not have happened and/or are without a reasonable basis. Facility staff are not qualified to provide care. On 5/2/2025 the Department received a complaint alleging that facility staff are not qualified to provide care. On 5/7/2025 Licensing Program Analysts (LPAs) Marcella Tarin and Manuel Monter investigated the allegation that facility staff are not qualified to provide care. Page 2 Out of 3. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 During the investigation, LPAs interviewed 6 staff S1-S6. All staff interviewed stated they have received training to provide care to residents. All staff interviewed stated all facility staff have been trained and are qualified to provide care. LPAs interviewed Resident R1-R10. 9 Out of 10 residents (R2-R10) stated facility staff has been providing adequate assistance with Activities of Daily Living (ADLs) such bathing, changing, escorting, etc. R1 stated facility staff are not qualified because they are not medically trained to give injections. LPAs interviewed Care Coordinator (CC). CC stated all staff receive training on how to care for residents. CC stated staff know how to perform their duties to include bathing, changing, escorting, etc. LPAs reviewed staff training records for the year 2025, which included in-service training but not limited to infection control, transfers/gait belt use, Dementia care and behaviors. The Department has completed the investigation of the above allegation. Based on interviews conducted and records review, the Department has found that the above allegation is UNFOUNDED , meaning that the allegation is false, could not have happened and/or are without a reasonable basis No deficiencies cited during today's visit per California Code of Regulations Title 22. An exit interview was conducted with Care Coordinator (CC) Gregg Madriaga and signed copy of this report was provided. Page 3 Out of 3.

Licensing Program Analysts (LPAs) Marcella Tarin and Manuel Monter conducted an unannounced Case Management to conduct a Non-Compliance Plan Quarterly Visit and met Care Coordinator Gregg Madrigaga. LPAs stated the purpose of the visit. Administrator Geralyn De Ocampo authorized for Gregg Madriaga to sign on her behalf. The purpose of the visit is to ensure the facility is adhering to the Compliance Plan submitted to Community Care Licensing (CCL) after an informal meeting held on October 22, 2024. CC tested all 5 delayed egress doors. All 5 delayed egress doors were working properly and free from any obstructions in both memory care and assisted living when tested by CC. LPAs toured the facility inside and out. LPAs did not observe any obstructions in the passageways. LPAs reviewed staff training such as, but not limited to: Understanding Dementia, completed on March 25, 2025. LPAs also reviewed staff training on Delayed Egress completed on 3/14/2025.. No deficiencies cited per California Code of Regulations, Title 22. An exit interview was conducted with Care Coordinator Gregg Madriaga and a copy of this report was provided.

LPA Monter interviewed staff S1-S8. S1 stated if R1 is agitated, will walk by himself/herself. S1 stated the care givers are there and will assist the R1 whenever R1 tries to walk. S1 stated that at night, R1 will try to get up and go to the bathroom, in his/her bedroom. S1 stated R1 will also sometimes go out of his/her room. S1 stated R1’s bed has an alarm that will notify staff if R1 gets out of bed. S2 stated R1 has an issue with his/her knee and loses balance. S2 stated R1 needs assistance in walking. S2 stated staff will go with R1 when R1 walks. S3 stated R1 needs assistance walking. S3 stated R1 has an unsteady gait and uses a wheelchair or walker that he/she doesn’t like to use. S4 stated R1 is unstable, so he/she assists R1 to ensure he/she doesn’t fall. S4 stated staff are supposed to watch R1 because he/she likes to try to walk by him/herself. S4 stated staff are supposed to assist R1 when he/she walks or a hand to keep R1 safe. S5 stated R1 is a rebellious resident. S5 stated R1 will listen sometimes and will not listen other times. S5 stated when he/she sees R1 walk, he/she will offer R1 the wheelchair. S6 stated R1 needs help with walking. S6 stated he/she has helped R1 walk a little. S6 stated that he/she has not had many interactions with R1. S7 stated when R1 walks around, he/she has an unsteady gait. S7 stated R1 holds onto the side rail when walking. S7 stated staff are supposed to assist R1 if he/she gets up or tries to walk. S7 stated R1 will try to get up in the middle of the night. S7 stated R1 will be put in bed and then will get up and walk around. S7 stated the night shift needs that supervision because R1 is a fall risk and likes getting up at night. S7 stated the night alarm goes off at night. S8 stated R1 can walk, but its unsteady. S8 stated they are supposed to keep an eye on R1 because he/she likes to get up on his/her own but has an unsteady gait. On March 7 & 13, 2025, LPA Monter interviewed staff S9-S11. S9 stated staff make sure they are watching R1 during their shift. S9 stated R1 wanders and is fall risk. S10 stated R1 was able to walk a little, but shaky and not stable. S10 stated staff was supposed to help R1 when he/she walks because he/she’s a fall risk. S11 stated he/she worked the night shift but doesn’t remember working with resident R1. Page 2 Out of 4. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Based on a review of R1’s Physicians report, dated June 3, 2024, R1 has a neurocognitive disorder. Based on a review of R1’s Appraisal/Needs & Services Plan (ANS), dated May 11, 2023, signed on December 15, 2023. The ANS states R1 has a neurocognitive disorder. The ANS states R1 is a fall risk. R1 also has a history of falls at home. R1 uses a walker but refuses to use it at times. The ANS states R1 also wanders at times. Under Objective/Plan, the ANS states to observe fall precautionary measures: provide a well-lighted room at all times, maintain a clutter free environment, remind R1 to seek staff’s assistance at all times, monitor for any changes in functioning skills. Based on a review of facility incident report, dated February 29, 2023, R1 sustained a fall on February 28, 2023 around 4:30am and was found sitting on the floor. Resident R1 returned to the facility after a few hours from the ER and had a right orbital fracture. Based on review of facility incident Report, dated March 23, 2023, R1 sustained a fall around 10:45am, while walking. A staff member who was closest to R1 was unable to catch R1 as he/she fell. Based on a review of facility Physician visit communication form, dated January 9, 2024. Attached to this communication was an after-visit summary form with stated “ER transfer patient with R Chest and R abdomen pain after probable fall.” Based on a review of facility incident report, dated January 18, 2024, R1 had sustained an unwitnessed fall around 5:30am on January 13, 2024. Resident R1 returned to the facility to the facility late in the afternoon. Based on a review of facility incident report, dated February 7, 2024, states at 7:30 R1 complained of knee pain. Staff gave medication and put R1 to bed. Staff walked along the hallway when he/she heard a crash sound. Staff saw R1 on the floor on his/her right side. R1 had no bumps or any redness, except for a bloody cheek. Page 3 Out of 4. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Based on a review of Facility incident report, dated March 7, 2024, R1 sustained an unwitnessed fall in the dining area at 7:30pm. Staff checked R1 over and there were no cuts bumps, scrapes. Based on a review of facility incident report, dated May 13, 2024, R1 was walking and lost balance and fell on floor, at 1:20pm. Staff checked up on R1. R1 stated he only felt pain his/her butt and a little in the back. Based on a review of facility incident report, dated May 24, 2024, R1 had sustained unwitnessed fall on 5/24/24, inside his/her room at 5:30am. R1 was bleeding on his/her forehead. Resident R1 returned to the facility the same day, around 1pm. Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED . Although it is a fact that resident R1 sustained falls at the facility, there is not a preponderance of evidence to prove that the allegations neglect/lack of supervision did or did not occur. Page 4 Out of 4. END OF REPORT.

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced Case Management to conduct a Non-Compliance Plan Quarterly Visit and met with Administrator Geralyn De Ocampo. The purpose of the visit is to ensure the facility is adhering to the Compliance Plan submitted to Community Care Licensing (CCL) after an informal meeting held on October 22, 2024. ADM tested the delayed egress door alarms, which were functional. LPA toured the facility inside and out. LPA did not observe any obstructions in the passageways. LPA reviewed staff training such as, but not limited to: Monitoring residents with wandering behavior, elopement risk, signal system operation, completed on November 12, 2024. LPA also reviewed In-service training on how to operate egress doors/ ensuring passageways are free of obstructions, completed on November 11, 2024. LPA also reviewed staff training by ANX hospice, regarding Dementia and behaviors, completed on January 31, 2025. LPA reviewed facility door check log, which is used to check doors are working properly and free from any obstructions in both memory care and assisted living. LPA received a copy of the Operational Compliance Plan. No deficiencies cited per California Code of Regulations, Title 22. This report was reviewed with Administrator Geralyn De Ocampo and a copy of the report was provided.

Licensing Program Analysts (LPAs) Marcella Tarin and Kenneth Madrigal conducted an unannounced case management visit regarding an incident report alleging sexual abuse that was submitted to the Department on 11/13/2024. LPAs met with Administrator, Geralyn de Ocampo. On 11/13/2024, the Department received an incident report stating on 11/12/2024, that someone touched resident R1's breast while watching TV. R1 was observed by staff to be confused and disoriented during this incident and R1 could not state who touched him/her, or state the time the incident occurred. On 11/14/2024, LPA's interviewed ADM. ADM stated R1 moved into the facility on 10/1/2024 and resides in Assisted Living. ADM states that she was informed of the incident by another care giver on the morning of 11/12/2024. AMD states that R1 started to become disoriented and confused prior to the alleged abuse on 11/11/2024. ADM states that this is the first time R1 has alleged sexual abuse. ADM states the facility is collaborating with R1's family and case manager to reassess R1's condition. LPAs interviewed staff. Staff S1 stated R1 is independent and enjoy doing exercises. S1 states she observed R1 disoriented and confused prior to the alleged abuse on 11/12/2024. S1 states on 11/10/2024, R1 was confused, having hallucinations and was refusing to participate in activities. S1 states she notified R1's nurse about the increase in confusion and hallucinations. Based on record review, R1 has neurocognitive impairment and mental health impairment. LPAs requested documentation to include: R1's needs/service plan, R1's physician's report, staffing roster for 11/11/2024, staff in-service training, and resident roster. No deficiencies were cited today per California Code of Regulations, Title 22. This report was reviewed with Administrator, Geralyn de Ocampo and a copy of the report was provided.

On 10/23/2024 San Bruno Regional Office - San Jose Unit conducted a non-compliance conference office meeting with Administrator Geralyn De Ocampo, Representative of Licensee Board Marife Duewel , Resident Care Coordinator Greg Madriaga, and Memory Care Manager Audie Tonod . Regional Manage Vivien Helbling, Licensing Program Manager Jackie Jin, and Licensing Program Analysts David Marrufo and Marcella Tarin were present in the meeting. During the non-compliance meeting, the following serious violations were discussed: 87303(a) Maintenance and Operation, 87307(d)(6) Personal Accommodations and Services, 87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities, and 87303(i)(1)(A) Maintenance and Operation. During this meeting, the compliance plan was developed and discussed with the licensee which includes more frequent monitoring inspection visits to ensure compliance with this compliance plan and Title 22 Regulations for 2 years. Licensee was provided the link below for resources and guidance to improve facility operations: https://www.cdss.ca.gov/inforesources/community-care/resource-guide-for-providers . An LIC421IM form issuing an immediate civil penalty of $500 was given to Marife Duewel, Representative of Licensee Board. The immediate civil penalty of $500 was issued today due to absence of supervision that occurred on 08/12/2024 in which a Memory Care resident eloped from the facility without staff supervision. This report was reviewed with Representative of Licensee Board Marife Duewel and Administrator Geralyn De Ocampo and a copy of the report and appeal rights were provided.

Licensing Program Analyst (LPA) Marcella Tarin and Licensing Program Manager (LPM) Jackie Jin conducted a case management to follow up on deficiencies that were cited on 10/10/2024. LPA and LPM met with Administrator (ADM) Geralyn De Ocampo. LPA and LPM observed all egress doors to be alarmed and functioning when tested. LPA and LPM toured 4 resident bedrooms. 3 out of 4 resident bedroom sliding glass doors were observed to be free of obstruction. 1 out of 4 resident bedroom sliding glass doors was observed to have a locking mechanism preventing the sliding glass door from opening. Maintenance staff unlocked the locking mechanism and the sliding glass door was opened. LPA And LPM advised ADM to create a log to check on resident's sliding glass doors and ensure they are not locked and free from obstruction. LPA Tarin cleared the deficiencies cited on 10/10/2024 during today's visit. A Letter of Deficiency Citations Cleared was printed and provided to ADM during today's visit. No deficiencies were cited during todays visit. A copy of this report was provided to ADM Geralyn De Ocampo.

Facility staff does not provide assistance to residents in turning and repositioning in bed: The allegation is that resident R1 was observed not being repositioned in bed for several hours by R1's family member. On 7/16/2024, LPA interviewed R1's family member (FM). FM refused to provide more detail information. On 7/17/2024, LPA interviewed Administrator (ADM) Geralyn De Ocampo. ADM stated the facility staff reposition bedridden residents every two hours. LPA interviewed caregiver S1. S1 stated he/she works for AM shift. S1 stated he/she met R1's family member (FM) in the weekend morning, but he/she was unsure on 7/6/2024 or 7/7/2024. S1 stated he/she repositions resident R1 every 2 hours during his/her shift. S1 stated he/she changed R1's diapers and repositioned R1 on 8:00AM, 10:00AM, and 12:15PM, and FM observed that. LPA interviewed Assisted Living Supervisor (S2). S2 stated he/she was at the facility on 7/7/2024 Sunday night and he/she knew FM was at the facility on 7/6/2024 and 7/7/2024. LPA interviewed Activity Director (S3). S3 stated he/she was on duty on 7/6/2024 and 7/7/2024. S3 stated FM came in the facility on 7/6/2024 afternoon and 7/7/2024 morning. LPA interviewed Med Tech and LVN S4. S4 stated he/she worked on 7/6/2024 PM shift and 7/7/2024 AM shift. S4 stated he/she saw FM on 7/6/2024 and 7/7/2024. LPA interviewed Med Tech and caregiver S5. S5 stated on 7/6/2024 afternoon he/she called R1's hospice care nurse to come to the facility because FM's request., LPA interviewed caregiver S6. S6 stated he/she worked on 7/6/2024 3:00PM to 8:00PM. S6 stated he/she repositioned R1 every two hours during his/her shift. Continue on LIC9099-C. Page 2 of 4. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Based on the review of R1's Appraisal Needs and Service Plan, R1 needs to be repositioned every 2 hours., Based on the review of R1's repositioning Log from 7/6/2024 to 7/11/2024, at 7/6/2024 8:00AM, 10:00AM, and 12:00PM were observed unchecked. R1's family member FM refused to provide more detail information regarding the allegation. Staff S1 stated he/she repositioned R1 every two hours but was unsure if the repositions were all documented. ADM stated staff are trained and instructed to reposition bedridden residents every two hours. Facility staff does not provide personal care to meet the resident's needs: The allegation is that facility staff does not provide personal care to meet resident R1's need and R1 was not being checked every two hours and was observed sweating in R1's room due to the air condition was not working. R1 was under hospice care. On 7/16/2024, LPA interviewed R1's family member (FM). FM refused to provide more detail information. On 7/17/2024, LPA interviewed Administrator (ADM). ADM stated resident R1 was under hospice care. and R1's medical and health condition was under the hospice care agency's management and supervision. ADM stated caregivers check R1 every two hours. ADM stated on 7/6/2024 R1 was observed condition change and the facility notified R1's hospice care agency. LPA interviewed 2 caregivers S1 and S6. Both stated they checked resident R1, changed R1's diapers, and repositioned R1 every two hours. LPA interviewed staff S2. S2 stated on 7/6/2024, resident R1 changed condition and refused to eat. Based on the review of R1' checking Log from 7/6/2024 to 7/11/2024, R1 was checked every two hours. Based on the review of R1 Appraisal Needs and Service Plan, staff to monitor R1's health condition, notify hospice care agency and family when changes in health condition. Comfort medications must be administered by R1's hospice care nurse. Assist R1's ADL at all time. Continue on LIC9099-C. Page 3 of 4. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LPA interviewed staff S3. S3 stated FM claimed the air condition of R1's room was not working on 7/6/2024. S3 stated the facility offered to change room for R1 on 7/6/2024. S3 stated FM refused R1 to relocate to another room. S3 stated the air condition of R1's room was fixed on 7/7/2024. LPA interviewed ADM. ADM stated the air condition of R1's room was not working on 7/6/2024 and the air condition was fixed on 7/7/2024. Based on the interviews and record reviewed, R1 was checked by the facility staff every two hours. R1's hospice care agency manages R1's health condition. The facility staff notified R1's change in condition to R1's hospice care agency nurse. Based on documents reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegation did or did not occur. No citations noted for today’s visit. Exit interview was conducted with MP. A copy of this report was provided to MP. Page 4 of 4. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Facility staff did not properly administer injections: The allegation is that the facility staff did not properly administer comfort medications injection for resident R1. R1 was under hospice care. R1's family member (FM) visited R1 on 7/6/2024 and observed R1 was painful. FM requested staff to administer comfort medication injection to R1. The facility staff replied to FM that the facility staff were unable to administer comfort medications to R1. On 7/17/2024, LPA interviewed ADM. ADM stated for the facility policy, only the facility nurse or licensed professionals can do the injection for residents. ADM stated for the hospice care residents, only the hospice agency nurse can do the injection. LPA interviewed staff S2. S2 stated the facility staff are not allowed to administer comfort medications to R1 who is under hospice care, only R1's hospice care nurse can administer comfort medications injection to R1. S2 stated the facility notified R1's hospice care nurse to come to administer the comfort medication injection after FM's request. LPA interviewed S3. S3 stated R1's hospice care nurse was at the facility on 7/6/2024 and 7/7/2024. S3 stated R1 was administered comfort medication injection on 7/6/2024 and 7/7/2024. S3 stated R1 was allowed to administer comfort medication every two hours as needed. S3 stated the hospice care nurse refused FM's request to administer comfort medication to R1 every two hours when R1 was calm and not painful. LPA interviewed staff S4 and S5. Both stated R1's hospice care nurse was at the facility to administer comfort medications to R1 on 7/6/2024 and 7/7/2024. Both stated the facility staff are not allowed to administer comfort medication injection to R1. Based on the review of R1 Appraisal Needs and Service Plan, staff to monitor R1's health condition, notify hospice care agency and family when changes in health condition. Comfort medications must be administered by R1's hospice care nurse. Continue on LIC9099-C. Page 2 of 3. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Based on the interviews and document reviewed, the facility staff are not allowed to administer comfort medications injection to R1. R1's hospice care nurse administered comfort medication injection for R1 on 7/6/2024 and 7/7/2024. The Department has investigated the above allegation. Based on the investigation, document reviewed, and interviews conducted, the Department found that the above allegation is UNFOUNDED , meaning that the allegation is false, could not have happened and/or is without a reasonable basis. No citations noted at today’s compliant investigation visit. Exit interview conducted with MP. This report was provided to review and for signature. A copy of this report was provided to MP.

Page 2 out of 2. On 7/31/2020 at 2:30PM, one of R1's children visited R1 and observed R1's injuries. The staff was not able to provide details on what happened to R1. R1's child accused the facility of physical abuse by not disclosing the information to him/her. He/She summoned 911 and law enforcement and they conducted investigation. ADM stated that R1's public guardian was informed about the incident. On 07/11/2023, LPA and LPM obtained and reviewed the following documents of R1, a copy of LIC624, a copy of SOC341, LIC601, LIC602A, a copy of care conference, R1's photo, and memory care Med-Tech endorsement dated 7/13/2020. LPA conducted an interview with Administrator (ADM) De Ocampo. ADM stated could not remember the exact details of the incident but what she could remember was that resident (R1) was out of balance when R1 was trying to sit down on a chair. ADM stated that the R1's nurse practitioner from Care More and public guardian were notified. ADM stated that R1's child was not contacted regarding R1's fall. ADM stated that R1's child came to visit and found R1's bruise on nose wherein he/she called 911 and law enforcement to report physical abuse against the facility. ADM stated that there were no reports or incidents that R1 was being physically abused by staff. On 07/11/2023, LPA conducted interviewed staff (S1), S1 stated that he/she called the public guardian and care home nurse regarding R1's incident. S1 stated S2 called S1 to report that S2 saw R1 about to sit down on the chair but missed sitting on the chair and fell but it was too late then to intervene. S1 stated that first aid was applied and R1 did not complain or unable to verbalize of any pain due to neuro-cognitive disorder. S1 stated that there were no reports of staff physically hitting or punching R1. S2 no longer employed by the facility. Based on overall investigation on physical abuse of R1, interviews with staff and records review revealed that R1 had a fall resulted an injury. There were no evidence of physical abuse. The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. No deficiencies cited, exit interview conducted with Administrator, Geralyn De Campo and a copy of the report was provided.

During interviews with 4 residents, 1 out of 4 residents stated that contracted facility staff had touched them inappropriately. 3 out of 4 residents had stated that they had never felt unsafe with staff nor been approached inappropriately while receiving care from staff. 4 out of 4 residents stated that they are satisfied with the quality of care provided by the facility. In interviews with facility staff 2 out of 2 facility staff members stated that they had never had any residents report or express concern over potential sexual assault at the facility. 2 out of 2 facility staff had never been given cause to suspect potential sexual abuse from other staff members, contracted or otherwise. In interviews with the facility's additional staffing contracting agency, Care On Call, one administrative staff stated that they have never had reports from Campbell Village regarding potential sexual assault. 3 out of 3 parties interviewed stated that the suspected abuser (SA) identified by 1 out of 4 residents had no prior history of abuse or misconduct on record. SA was discharged from Campbell Village and no longer works for Care On Call for reasons outside of alleged incident. During course of investigation, The department made 4 attempts to interview SA. After agreeing to meet with the department, SA failed to arrive at the designated meeting location, and was unable to be contacted afterward. As of 01/01/2022, SA has been unable to be contacted by both police and department investigators. The Department has investigated the above allegation. Based on interviews conducted and records reviewed, the Department found that the above allegation is UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegation did or did not occur. This report was reviewed with Administrator Geralyn de Ocampo and a copy of the report was provided.

Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 10/12/2021 at 01:32pm. LPA met with facility Administrator Geralyn de Ocampo (Admin). LPA toured the facility, including living room, kitchen, dining room, laundry room, 6 bedrooms, 2 public bathrooms, back patio, front yard, salon, activities room, dining room, and kitchen. All staff members observed to be wearing masks. Admin confirmed that all staff and residents have been vaccinated. Facility Mitigation plan has already been submitted. No prohibited items noted in resident rooms. All emergency exits noted to be clear of obstruction. All rooms in facility noted to be clean and well maintained. Hand sanitizers, soap, and paper supplies were observed to be available. At least 2 days' supply of perishable food and at least 1 week's supply of non-perishable food was observed on the premises. Fire extinguishers observed to be inspected in February of 2021. Facility observed to have designated entry point. Staff took LPA's temperature and screened for symptoms. 30 day supply of PPE observed. All restrooms stocked with paper towels. Water temperature observed to be 111.7 *F. Hand washing signs observed in all bathrooms. All bathrooms had garbage cans with foot operated lid. Social distancing signs observed to be posted in all public areas. The facility is currently accepting visitors inside the facility, including residents' bedrooms. The facility has reached a 99% COVID-19 vaccination rate for staff and 99% for residents. No deficiencies cited during today's visit. This report was reviewed with Administrator Geralyn de Ocampo and a copy of the signed report was provided.