Palm Villas, Campbell

Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to conduct a Case Management-Incident visit regarding the elopement of a resident from the facility on 11/30/2025. LPA met with Community Director (CD) Michelle White. LPA stated the purpose of the visit. On 12/3/2025 the Department received an incident report regarding the elopement of Resident R1 on 11/30/2025. The incident report states on 11/30/2025, at approximately 8:30PM staff were unable to locate R1 at the facility. Staff immediately began a search of the surrounding neighborhood, both on foot and by vehicle. At approximately 8:55PM police contacted the facility regarding R1 being located at the Wing Stop (on the corner of Bascom Ave and Camden Ave). R1 was returned to the facility on the same evening and was not injured during the elopement. During today's visit, LPA interviewed staff and 1 resident. LPA requested pertinent documentation to include but not limited to physicians reports, service plans, preplacement appraisals, and staff schedules. LPA determined this case management requires further investigation. No deficiencies were cited during today's visit per California Code of Regulations, Title 22. An exit interview was conducted with CD and a copy of this report was provided.

out of 3 staff state R1 is receiving palliative care and receives palliative care five 5 days a week. LPA interviewed 5 residents (R1 to R5). 4 Out of 5 residents did not provide information due to neurocognitive disorder. R5 states the staff are taking great care of him/her and has no issues with the care he/she is receiving. LPA reviewed R1’s physician’s report dated 6/1/2025, which states R1 has neurocognitive disorder and is receiving palliative care. LPA reviewed R1's care plan dated 8/7/2025, which states R1 is Max assist with bathing, dressing, grooming, dental, transfer and mobility, and cognitive. LPA reviewed R1's comprehensive palliative care plan dated 10/9/2025, which states R1 is receiving treatment from skilled nurses, palliative aides, and palliative volunteers since 10/11/2025. Facility staff did not provide resident with activities. On 10/20/2025 LPA Tarin interviewed 3 Staff (S1 to S3) and 5 Residents (R1 to R5). 3 Out of 3 staff R1 is being provided activities in his/her room due to ambulatory status. S3 states palliative care volunteers visit with R1 twice a month and provide R1 with activities such as music therapy and pet therapy. LPA interviewed 5 residents (R1 to R5). 4 Out of 5 residents did not provide information due to neurocognitive disorder. R5 states he/she participates in the facility activities, but did not recall the specific activities. LPA reviewed the facility's October 2025 activities calendar to included art activities such as art appreciation and physical movement activities. Facility staff did not safeguard residents personal belongings. On 10/20/2025 LPA Tarin interviewed 3 Staff (S1 to S3) and 5 Residents (R1 to R5). 3 Out of 3 staff R1 has not had of his/her personal belongings go missing. 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 LPA interviewed 5 residents (R1 to R5). 4 Out of 5 residents did not provide information due to neurocognitive disorder. R5 states he/she has not had any of his/her personal belongings go missing. LPA reviewed R1's safeguard for personal property and valuables, which was declined (no items listed) by R1 upon move-in on 9/8/2020. LPA reviewed incident reports for R1 and did not observe reports for missing personal belongings. Facility staff are not meeting residents dietary needs. On 10/20/2025 LPA Tarin interviewed 3 Staff (S1 to S3) and 5 Residents (R1 to R5). 3 Out of 3 staff R1 has a thin/liquids diet, which is provided to R1 by facility staff. S3 states R1 is on a thin/liquids diet as part of R1's care plan. LPA interviewed 5 residents (R1 to R5). 4 Out of 5 residents did not provide information due to neurocognitive disorder. R5 states he/she is provided 'healthy' meals by the facility and enjoys the food. LPA reviewed R1’s physician’s report dated 6/1/2025, which states R1 has a modified diet consisting of thin liquids, which is being provided by facility staff. LPA reviewed R1's service plan dated 8/7/2025, which states for 'Meals and Nutrition' R1 needs 'Max assistance' with a soft/thin liquids diet provided by facility staff daily. This agency has investigated the complaint alleging the facility neglected resident in care, facility staff did not provide resident with activities, facility staff did not safeguard residents personal belongings, facility staff are not meeting residents dietary needs. We have found that the complaint was UNFOUNDED , meaning that the allegations were false, could not have happened and/or are without a reasonable basis. An exit interview was conducted, and a copy of this report was provided. Page 3 of 3 END OF REPORT.

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced annual inspection and met with Designated Administrator (DA) Michelle White. LPA stated the purpose of the visit. LPA toured the interior and exterior of the facility with DA to include but not limited to the kitchen, resident rooms, dining room, bathrooms, back and front of the facility. All exit and passageways were free and clear of obstruction. LPA observed video surveillance of the courtyard/entrance to the facility. LPA observed cameras in the hallways of the facility. DA states the cameras are non-operational. DA states the courtyard/entrance is the only area with video surveillance in the facility. LPA 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. LPA observed refrigerator temperature at 36F and Freezer at -5F. LPA 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 last inspected by a third party vendor on 3/14/2025 and passed inspection. Fire extinguishers were last serviced on 3/10/2025. 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 LPA reviewed the facility first aid kit, and it was observed to be complete. The facility emergency drill log was reviewed and drills are being conducted monthly. The facility's last drill was on 5/21/2025. LPA toured 10 random resident bedrooms. 10 Out of 10 resident rooms have a bed, functioning lights, dresser/table, bedding and space for personal belongings. LPA measured water temperature in 7 resident bathrooms with a range of 113.3 F to 119.6 F. LPA reviewed 4 resident records. Resident records included emergency contact information, physician’s report, needs and service plans, and personal rights. LPA reviewed 4 resident’s Centrally Stored Medication and Destruction Records (CSMDR’s). LPA reviewed 4 staff records. Staff records included fingerprint background clearance, medical assessment with TB result, personnel record, and staff training. No deficiencies were cited during today's visit per California Code of Regulations Title 22. An exit interview was conducted with Designated Administrator Michelle White and a signed copy of this report was provided.

LPA interviewed Staff S1. S1 states R1 was taken to the hospital on 6/3/2025 and is still at a SNF. Based on interview and documentation review, R1's injuries did not occur at the facility as R1 was taken to the hospital on 6/3/2025 and was then transferred to a SNF. As of 6/19/2025, R1 has not returned to the facility. This agency has investigated the complaint alleging that facility neglected resident in care causing resident to sustain injuries . 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 Staff Jimena Pulido, and a copy of this report was provided.

S1 states he/she and a Private Caregiver (referred to as PC) were in the dining area. S1 was serving lunch to a resident. S1 states he/she observed R1 touch R2 on the arm and stomach. S1 states he/she then heard R2 tell R1 to not touch him/her. S1 stated when he/she saw/heard this, he/she walked towards both residents. S1 stated while he/she was walking towards R1 and R2, that is when R1 touched R2 again, and R2 pushed R1 causing R1 to fall to the ground. S1 stated this all happened in less than 10 seconds. During interviews both individuals were busy with clients when then heard R1 and R2 arguing. Staff S11 stated he/she had just clocked in the day of the incident. S11 stated he/she was in the staff lounge area walking towards the dining room. S11 stated as he/she entered the dining room, S11 stated he/she saw R2 make contact with his/her arm toward R1, and saw R1 fall. S11 described the hand motion as a swiping motion, in R1's direction. S11 stated he/she saw S1 walking in the direction of both R1 and R2. S11 stated S1 was in the middle of the dining area, when the incident occurred. Residents were in the dining area at approximately 2PM, S1 heard R1 and R2 talking and heard R2 state “Don’t touch me” to R1. According to staff, they heard R1 and R2 briefly exchange conversation. LPAs interviewed PC on 4/1/2025 and states he/she was in the middle of the dining room on 11/15/2024. PC states that he/she was taking care of his/her resident when he/she observed R1 push R2. PC states that S1 went over to assist R1 when R2 pushed R1 down to the ground. LPAs interviewed 6 residents, R1-R5. 3 Out of 6 residents stated they did not observe the incident between R1 and R2. 3 Out 6 residents did not respond to questions due to neurocognitive disorder. LPAs reviewed physician’s reports for R1 and R2. R1’s physician’s report dated 12/3/2024 with a primary diagnosis of neurocognitive disorder , associated with “confusion, and sundowning behavior.” On the other hand, R2’s physician’s report dated 3/15/2023 with a primary diagnosis of neurocognitive disorder, associated with a mental condition of ‘confusion, inappropriate behavior and aggressive behavior.’ 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 ’LPAs reviewed R1 and R2’s appraisal needs and care plans dated 12/11/2023 and 12/27/2023. R1 and R2 have similar behaviors of aggression due to his/her neurocognitive disorder wherein both residents require supervision by staff. LPAs obtained and reviewed staff daily notes for R1 from 11/19/2024-12/11/2024. R2 had a previous incident documented on 8/16/2024, where R2 had aggressive behavior involving foul language and being physically too close to another resident. The Department has completed the investigation of the above allegation. Based on interviews conducted and record reviews, the Department has found that the above allegation is UNSUBSTANTIATED. Although the allegation that resident R1 pushed R2 is true, there is not a preponderance of evidence to prove that the allegations did or did not occur. An exit interview was conducted with Activities Director Michelle White and a copy of the report was provided.

Licensing Program Analysts (LPAs) Marcella Tarin and David Marrufo conducted an unannounced required 1 year visit and met with Administrator Garry Sneper. During visit LPAs toured the facility inside and out. LPAs toured the facility kitchen area. LPAs observed a perishable food supply of at least 2 days and a nonperishable food supply of 7 days. LPAs observed storage area with cleaning supplies and tools. The storage area was locked and inaccessible to residents. LPAs toured 1 hallway bathroom and measured the water temperature to be 114 degrees Fahrenheit. The bathroom had functioning lights and available soap and paper towels. LPAs toured 7 resident rooms. Each room had working lights, and available bedding and clothing storage areas. LPAs toured the bathrooms in each bedroom and found them to have working lights, available soap and paper towels. Water temperatures in the toured resident bathrooms ranged from 114 degrees Fahrenheit to 119 degrees Fahrenheit. LPAs tested the smoke detectors in each room, and observed the smoke detectors to be functioning properly. The smoke detectors also function as carbon monoxide detectors. LPAs tested 1 hallway carbon monoxide detector and it functioned properly. LPAs observed 2 resident exits to be clear of obstruction, and 1 out 1 tested alarmed exit tested properly when tested. LPAs reviewed 7 resident Centrally Stored Medication and Destruction Record (CSMDR). Each reviewed CSMDR was complete during visit. LPA's reviewed 7 resident records, R1-R7. Resident R2 and Resident R4 did not have Appraisal Needs and Service Plan. Resident R5 is missing the first page of the Safeguard for Property and Valuables form. LPAs reviewed 7 out of 7 staff records to be complete. The last conducted Fire Drill is recorded at 5/20/2024. Advisory notes were issued. See LIC 9102 pages for more information. No deficiencies were cited as per California Code of Regulations Title 22. This report was reviewed with Administrator Garry Sneper. A copy of this report was provided.

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced Collateral visit and Met with the facility Medication Manger Jimena Pulido (MM). The purpose of the visit was to interview resident R1 and to collect R1's medical records as part of a complaint investigation of another licensed facility.. During the visit, LPA interviewed MM, resident R1, and 3 staff (S1 - S3). LPA toured the bedroom of R1 with MM. LPA requested R1's medical records and medical notes. No deficiencies cited today. The report was provided to MM for signature. A copy of the report was provided to MM.

On 2/8/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced case management visit. LPA met with Administrator Garry Sneper & Office Manager Myra Belza. LPA explained the purpose of the visit. LPA is delivering 2 amended reports for the following complaints: 26-AS-20220225121016 26-AS-20220412110249 No deficiencies cited today. Report is reviewed and copy is provided.

Regarding the allegation of staff are not providing a comfortable environment for residents, RP stated that there were residents eating lunch outside in the heat and there was no staff around. According to S2, residents don't have lunch outside unless there are activities. Residents can freely roam around the facility, whether just sit outside the patio or go around inside the facility. Facility has also enough staffing to be able to cater to the residents. Regarding the allegation of staff are restricting residents visitors from certain areas in the facility , RP stated that visitors are not allowed to go in the dining room or the living room. LPA confirmed with Administrator Garry Sneper that there hasn't been any restrictions since the facility was cited in January of 2023 for another complaint. The facility has been compliant with visitations. Facility only has suggestions and recommendations for family members when visiting the facility. For the allegation of st aff are not providing activities for residents , RP stated that there were no activities happening. RP stated that the residents were sitting around doing nothing. RP stated that there was no TV or anything else happening. According to S2, the activity coordinator emails the staff for the activities to be done each month. The facility staff can't force the residents to join the activities if they are not up to it but they do certainly try to encourage residents. LPA also obtained the activities calendar during this month and it shows a full set of activities per day. LPA was able to interview a resident (R1) and stated that they like and enjoy the activities done in the facility. R1 also mentioned that sometimes they watch movies in the TV. LPA attempted to interview other residents but wasn't able to get answers due to cognitive issues. Based on interviews and record reviews, the department has determined that the allegations are UNFOUNDED, meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. The report was reviewed, and a copy is provided.

Based on interviews by LPA Heberle, two staff members mentioned that there never was an issue of residents having mismanagement of medications. On staff member (S1) stated that the facility does not have any involvement in which medications residents are taking. The family can make request that the facility administer certain medications, but staff always makes sure the doctor okays and prescribes it first. The facility communicates with doctors if they believe the medication needs to be changed. LPA Heberle & LPA Donato was also able to interview residents and two out of five mentioned that they don’t have any issues with medications, and they are able to get it on time. Three residents were not able to respond to questions due to cognitive diagnosis.. LPA Donato was able to review records for R1, and according to the centrally stored medication, facility gave the medication according to doctors’ orders. Therefore, based on the interviews conducted, files reviewed, and information collected, the allegations mentioned are UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. The report was reviewed, and a copy is provided.

Regarding the allegation of facility restricting visitation, RP stated that visits were only 30 mins. Based on interviews, S1 stated that RP is allowed to visit every day. No visitor has been denied visitation in the facility. They have scheduled visitation during this time. Even if visitors don’t have a schedule around this time, the facility still lets them in. Family visits are always accommodated. Depending also on the residents, the facility requests that they delay visitation for up to a week to allow for assimilation. It is never mandatory; it is only a recommendation. LPA reviewed visitation logs and it showed that RP was able to sign in and temperature was checked upon entering the facility as well as other visitors visiting other residents. Based on records review, the facility was also following some COVID-19 protocols during this time. Visitation is allowed but Screening protocol is followed, scheduled visitation, well-fitting face mask are always required upon entry and within the facility. Limit the number of visitors on the facility premises at any one time to avoid having large groups congregate. Facility encourages short indoor visits and longer outdoor visits. Regarding the allegations resident’s sustained unexplained injuries and staff not reporting an incident to resident's representative. RP said the staff never reported a skin laceration to RP, RP stated that On 10/1/2021 staff reported to RP that R1 had a lemon size bruise on the outer arm. Based on record reviews, this incident happened around 9/27/21 where staff found a skin discoloration on R1’s right arm. This skin discoloration was observed by staff during routine checks done in the facility. There were no prior incidents that happened before this, so it is hard to determine how R1 sustained this skin discoloration. On the progress reports for R1, its was stated there that incidents were all reported to physician and responsible parties. These incidents were also reported to Licensing. Therefore, based on the interviews conducted, files reviewed, and information collected, the allegations mentioned are UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Report is reviewed and a copy is provided.

Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced case management visit regarding the facility's current probationary license. LPA met with facility Resident Services Director Blyth Obien (RSD) and Administrator Garry Sneper (Admin). LPA toured the facility with RSD. During tour of the facility, LPA observed the facility to be operating within regulation, including compliance with personal rights and allowable health conditions. LPA observed the facility's probationary license posted both on the bulletin board outside of the Administrators office, as well as framed in the receptionist's office and in the waiting room outside of administrative offices. The facility currently has one resident utilizing home health services. LPA reviewed the resident's home health agreement, and confirmed via visitation reports that home health had been providing service as stipulated in the agreement. RSD is still the facility infection prevention specialist. LPA reviewed RSD's IP certifications and verified that RSD's training records are up to date and complete. No additional administrator training documentation has been generated since case management inspection on 07/12/2022. Admin has already completed all necessary course work. In review of administrator application packet, LPA confirmed that Admin submitted administrator renewal application packet on 07/05/2022. No deficiencies cited during today's visit. This report was reviewed with Resident Services Director Blyth Obien and a copy of this report was provided.

Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced case management visit regarding the facility's current probationary license. LPA met with facility Resident Services Director Blyth Obien (RSD). LPA toured the facility with RSD. During tour of the facility, LPA observed the facility to be operating within regulation, including compliance with personal rights and allowable health conditions. LPA observed the facility's probationary license posted both on the bulletin board outside of the Administrators office, as well as framed in the receptionist's office and in the waiting room outside of administrative offices. The facility does not currently have any residents that are utilizing home health agreements. The only resident that had been under home health previously is now under hospice services instead RSD is still the facility infection prevention specialist. IP qualifications have been previously reviewed by LPA. No additional administrator training documentation has been generated since case management inspection on 07/12/2022. Admin has already completed all necessary course work. No deficiencies cited during today's visit. This report was reviewed with Resident Services Director Blyth Obien and a copy of this report was provided.

Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 08/04/2022 at 1:05pm. LPA met with Palm Villas Administrator Nora Saavera (S1). Administrator Gary Sneper (Admin) was currently on vacation and was unable to attend the inspection. LPA was informed that Admin would be on vacation during inspection that took place on 07/12/2022. During 07/12/2022 inspection Admin stated that S1 would be able to sign reports in his stead. LPA toured the facility, including courtyard, front offices, medication room, dining hall, kitchen, TV room, all facility bathrooms, 10 resident rooms, kitchen, laundry room, front offices, storage room, and break room. All staff members observed to be wearing masks. Hand washing, cough sneeze etiquette, and social distancing signs observed in all facility common areas. Facility observed to have designated entry point. Staff took LPA's temperature and screened for symptoms. LPA observed all facility bathrooms to have adequate supply of paper supplies and soap. LPA observed that bathroom garbage cans have lids. When inspecting facility, LPA noted that facility had over 30-days worth of N95s, gowns, gloves, face shields, and booties. Kitchen observed to have adequate supply of perishable and nonperishable food. Water temperature tested in facility bathroom and observed to be 113.5*F. Facility temperature noted at 77*F. Facility fire extinguishers were noted to have been inspected in May of 2022. No deficiencies cited during this inspection. This report reviewed with Palm Villas Administrator Nora Saavera and a copy of the signed report was provided.

Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 08/04/2022 at 1:05pm. LPA met with Palm Villas Administrator Nora Saavera (S1). Administrator Gary Sneper (Admin) was currently on vacation and was unable to attend the inspection. LPA was informed that Admin would be on vacation during inspection that took place on 07/12/2022. During 07/12/2022 inspection Admin stated that S1 would be able to sign reports in his stead. LPA toured the facility with S1. During tour of the facility, LPA observed the facility to be operating within regulation, including compliance with personal rights and allowable health conditions. LPA observed the facility's probationary license posted both on the bulletin board outside of the Administrators office, as well as framed in the receptionist's office and in the waiting room outside of administrative offices. LPA confirmed maintenance of home health agreements. No additional home health agreements have been created since visit on 07/12/2022 No additional administrator training documentation has been generated since case management inspection on 07/12/2022. Admin has already completed all necessary course work. No deficiencies cited during today's visit. This report was reviewed with Palm Villas Administrator Nora Saavera and a copy of this report was provided.

Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced case management visit regarding the facility's current probationary license. LPA met with facility nurse Blythe Obien (LVN). Administrator Gary Sneper (Admin) was at the Redwood City facility upon LPA's arrival, and arrived at 11:15am to review the report. LPA toured the facility with LVN. During tour of the facility, LPA observed the facility to be operating within regulation, including compliance with personal rights and allowable health conditions. LPA observed the facility's probationary license posted both on the bulletin board outside of the Administrators office, as well as framed in the receptionist's office and in the waiting room outside of administrative offices. LPA confirmed maintenance of home health agreements. LVN identified herself as the facility's Infection Prevention (IP) specialist. LVN stated that they had been working at the facility since June. LPA reviewed LVN's IP training certificates. Records indicated that between the days of 06/05/2022 and 06/11/2022, LVN completed 17 courses related to infection prevention. LPA confirmed completion of staff training on infection prevention. During the inspection, LPA reviewed administrator training documentation. During records review, LPA observed that from the dates of 02/03/2022 to 03/15/2022, Admin completed 42 hours of training. No deficiencies cited during today's visit. This report was reviewed with facility Administrator Gary Sneper and a copy of this report was provided.

Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced case management visit regarding the facility's current probationary license. LPA met with facility administrators Brisa Romero (Admin 1) and Gary Sneper (Admin 2). LPA toured the facility with Admin 1. During tour of the facility, LPA observed the facility to be operating within regulation, including compliance with personal rights and allowable health conditions. LPA observed the facility's probationary license posted both on the bulletin board outside of the Administrators office, as well as framed in the receptionist's office. LPA confirmed maintenance of home health agreements. Admin identified licensed vocational nurse Melissa Bray (LVN) the facility's Infection Prevention (IP) specialist. LPA observed RN working at the facility during the inspection. In interview with LVN, LVN stated that they had been working at the facility since February. LPA reviewed LVN's IP training certificates. Records indicated that between the days of 02/11/2022 and 02/15/2022, RN completed 17 courses related to infection prevention. LPA confirmed completion of staff training on infection prevention. During the inspection, LPA requested administrator training documentation. During records review, LPA observed that from the dates of 02/03/2022 to 03/15/2022, Admin 2 completed 42 hours of training. Facility request to lift probationary period is currently under review No deficiencies cited during today's visit. This report was reviewed with facility administrator Brisa Romero and a copy of this report was provided.

Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 08/20/2021 at 1:28pm. LPA met with facility administrator Brisa Romero (Admin). LPA toured the facility, including courtyard, front offices, medication room, dining hall, kitchen, TV room, all facility bathrooms, 5 resident rooms, kitchen, laundry room, front offices, storage room, and break room. All staff members observed to be wearing masks. Hand washing, cough sneeze etiquette, and social distancing signs observed in all facility common areas. Facility observed to have designated entry point. Staff took LPA's temperature and screened for symptoms. LPA observed staff members signing in to facility and following COVID-19 precautions. LPA observed all facility bathrooms to have adequate supply of paper supplies and soap. LPA observed that bathroom garbage cans as have lids. When inspecting facility, LPA noted that facility had over 30-days worth of N95s, gowns, gloves, face shields, and booties. Kitchen observed to have adequate supply of perishable and nonperishable food. Water temperature tested at 4 faucets in facility with temperature ranging from 110.3*F to 113.5*F. No deficiencies cited during this inspection. This report reviewed with Administrator Brisa Romero and a copy of the signed report was provided.

Licensing Program Analyst Ryker Heberle (LPA), Licesnsing Program Manager Sarah Yip (LPM), and Regional Manager Vivien Helbling (RN) conducted a collaborative tele-visit meeting with facility administrator Garry Sneper (Admin), along with additional facility administrative staff Mike Sneper and Brisa Romero. During the meeting, RN elaborated on the stipulation order regarding Forever Young's license revocation, which has been stayed with probation from April 14th 2021 to April 14th 2023 pursuant to the following conditions: A) Facility shall operate strictly within regulation B) Facility shall grant The Department discretion and inspection authority C) Facility must maintain compliance with personal rights, reporting requirement, and allowable health condition regulations D) Facility must maintain strict compliance with COVID-19 policies and regulations E) Within 60 days of execution of this stipulation, Facility must employ infection control nurse and COVID-19 mitigation plan. Admin indicated that the facility already maintains an infection control nurse on staff and that they will resubmit mitigation plan F) Facility shall be keep clean, safe, sanitary, and in good repair G) Facility shall maintain home health agreements for all clients H) Within 90 days of execution of this stipulation, facility must provide training for all staff on COVID-19 infection control via medical professional and provide training record to The Department I) This stipulation must be posted in a conspicuous place within the facility for the duration of probation Continued in 809-C 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 The revocation of Admin's administrator certificate shall also be stayed with probation from April 14th 2021 to April 14th 2023. Admin shall be granted a probationary certificate pursuant to the following conditions: A) Admin shall complete 20 hours of training in addition to any training courses required to maintain administrator certificate. This training shall be completed during the second year of Admin's probation B) The stay of Admin's certificate shall only apply to facilities currently operated by Forever Young Inc. Admin cannot act as administrator of any other facilities during probation RN also went into further detail on the remaining sections of the stipulation including future application for a license registration certification or approval, tolling of probationary period, completion of probation, violation of stipulation term, Department's authority, monitoring fee, waiver of hearing rights, waiver of appeal/modification rights, waiver of claims, public record, signatures, counterparts, effective date, no oral modification, and representations RE: corporate licensee. RM asked meeting participants if they had any questions or required any further clarification on the conditions of the stipulation order. Admin asked for clarification on monitoring fees. Upon receiving answer from RN, all meeting participants indicated that they understood the stipulation order. Admin inquired about whether the revocation status of Palm Villas, Campbell would be removed from the website. RN indicated that the matter is currently being resolved by legal team. No deficiencies cites during this visit. This report was reviewed with Garry Sneper, Administrator, and a copy of this report was provided electronically for signature.

On 12/11/20 Licensing Program Analyst (LPA) Ryker Heberle, Regional Manager (RM) Vivien Helbling, and Program Clinical Consultant (PCC) Helen Shi conducted a technical assistance tele-visit via Facetime. LPA, RM, and PCC met with facility Executive Director Brisa Romero (Admin). Admin gave Licensing a tour of the facility, including the entry courtyard, main hallway, communal dining area, shower rooms, isolation area, 2 resident rooms, 2 public bathrooms, staff break room, laundry room, back courtyard and TV room Facility nurse demonstrated donning and doffing procedure for entry into isolation area The department observed residents participating in various activities in the communal dining area, residents appeared healthy and well groomed. The department interviewed two residents, who were both in good spirits. Residents in dining room were not observed to be wearing masks. PCC made the following recommendations: Remind residents to wear masks outside of rooms Request LVN to emphasize seal test and use of hand sanitizer during donning and doffnig procedure Put up hand washing posters in resident bathrooms No deficiencies were cited on this tele-visit. Exit interview conducted. This report was reviewed with Executive Director Brisa Romero and an electronic copy was provided for signature on 12/11/2020

On 11/13/20 Licensing Program Analyst (LPA) Ryker Heberle, Regional Manager (RM) Vivien Helbling, and Program Clinical Consultant (PCC) Helen Shi conducted a technical assistance tele-visit via Facetime to follow up on a technical assistance tele-visit that occurred on 11/9/2020. LPA, RM, and PCC met with facility Executive Director Brisa Romero (Admin). Admin gave Licensing a tour of the facility. Tour started in the facility courtyard, where The Department observed a medicine cart located directly next to the entry gate. Medcart is now being used as universal check in station as opposed to the front desk. Medcart was observed to be stocked with PPE, hand sanitizer, and universal symptom screening forms. The Department was given a tour of the dining area, back patio break area, TV room, and staff break room. These common areas were observed to adequately meet social distancing and infection protection standards. The department requested to be shown the bathrooms in the former infection wing. Bathrooms with bathing capabilities had reusable towels despite HFEN recommending that towels be removed during previous tele-visit. Admin clarified that they are currently waiting on the delivery of cabinets to store towels. LPA recommended Admin temporarily relocate towels until cabinets arrive. Admin indicated that the staff had begun fit testing for N95s, but some staff members had not yet been tested. PCC stressed the importance of fit testing to Admin and encouraged Admin to get the rest of the staff tested as soon as possible. Report continued on 809-C 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 Resident was observed in their room eating. Resident finished the majority of their meal, was well groomed, and seemed in good spirits. Department observed two residents resting in their shared room. Residents were adequately distanced and room was set up to adhere to social distancing specifications. While observing laundry room, department noted that cleaning solution had a current date and time stamp. Adequate supplies were observed in the facility offices and basement. No deficiencies were cited on this tele-visit. Exit interview conducted. This report was reviewed with Executive Director Brisa Romero and an electronic copy was provided for signature on 11/13/2020.