Carefield Castro Valley.

On 01/08/2026 at 10:00 AM Licensing Program Analyst (LPA) Ardalan Gharachorloo arrived unannounced to deliver the amended report for the complaint #15-AS-20250718094347. LPA met with Executive Director, Parveen Singh and explained the purpose of the visit. Amended report delivered to Executive Director. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

***CONTINUE FROM 9099*** W1 stated that R1 was not being reminded to eat and was possibly experiencing health decline as a result, including needing a blood transfusion. S1 explained that dietary needs are determined through physician assessments and then communicated to the kitchen staff. The Assisted Living Director works closely with the culinary team to ensure preferences and restrictions are followed. S3 and S4 stated that caregivers and servers monitor who attends meals and report non-attendance or poor appetite to the med tech. S3 said, “We always notice if someone hasn’t eaten. We either check on them or bring a meal to their room.” S4 recalled R1 having occasional fluctuations in appetite but said, “She tells us when she doesn’t like something. She’s very clear.” R1 stated she typically eats in the dining area but sometimes feels tired or forgets, and on those days, someone usually reminds her or brings food to her room. She added, “If I want something, I ask. They usually help.” R2 stated that R1 is socially active and frequently seen in the dining room. Review of meal-related documentation did not show consistent patterns of meal refusal or weight loss. Care notes indicated regular dietary monitoring and no recent physician concerns about nutritional status. Allegation: Staff do not seek timely medical attention for residents - Unsubstantiated W1 stated that R1 had to receive a blood transfusion due to poor medical follow-up and that there was little coordination with her physician. S1 acknowledged that contacting outside providers, particularly Kaiser, can be challenging due to call wait times and follow-up delays. However, S1 and S2 stated that when a family member or resident informs them of a health issue, staff follow protocol by alerting the med tech and care coordinator, and contacting the provider. S5 added, “We’ve had to call Kaiser multiple times to get things moving. It’s not us ignoring anything—it’s just delays from their side.” ***CONTINUE ON 9099C*** 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 ***CONTINUE FROM 9099C*** R1 confirmed that she has experienced delays getting doctor appointments but said staff helped her make calls or forwarded messages. She stated, “They try to help, but Kaiser is slow. I get frustrated, but I don’t blame them.” R2 did not report any issues with medical attention but stated that she manages most of her own appointments. Review of communication logs and incident reports showed attempts by staff to follow up on R1’s medical needs, including calls and coordination of transportation. Allegation : Licensee does not ensure enough staff to meet residents’ needs - Unsubstantiated W1 reported that R1 calls late at night asking for help and expressed concern that the facility may be understaffed or unresponsive during the day. S1 stated that the facility maintains a staffing ratio of approximately 1 staff per 10 residents in Assisted Living, and there are typically 5 to 6 staff members per shift. Staff schedule for 04/25/2025 confirmed this ratio. S2 explained, “We have coverage across all shifts. If someone calls out, we have floaters or back-ups.” S4 and S5 both stated that they check in with residents throughout the day and respond to call buttons promptly. S4 noted, “If someone says they’re not getting attention, it’s probably because they didn’t let us know. We try to anticipate needs, but we can’t guess everything.” S5 added, “We always have someone walking the floor.”R1 confirmed that staff generally respond when she presses her call pendant, though she mentioned she sometimes calls her family late at night because she “just feels anxious.” She said, “It’s not that they’re not helping me—it’s more that I don’t want to bother them sometimes.” R2 reported no concerns about staffing levels or response times. Review of staffing records did not indicate staffing shortages. ***CONTINUE ON 9099C*** 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 ***CONTINUE FROM 9099C*** Allegation : Staff are not dispensing medication as prescribed - Unsubstantiated W1 stated that R1 has a prescription for anxiety that was never filled and expressed concern about medications that are supposed to be taken every three hours. S1 stated that all medications are managed using MARs and administered by trained med techs. S3 explained that medication times are scheduled based on physician orders and any special instructions are clearly marked. S3 stated, “We’re very strict with the med passes, especially for time-sensitive meds. We double-check the MAR each shift.” S5 added that when a prescription is delayed due to pharmacy or provider issues, it is documented and the family is informed. According to S2, the anxiety medication W1 referred to had not been delivered by the pharmacy and was under follow-up .R1 acknowledged that one of her medications hadn’t arrived yet but said she was aware of the reason and had spoken to staff about it. “They told me they’re waiting on it from the doctor. I’ve been okay,” she said. R2 reported no issues with medication timing or availability. Review of MARs confirmed consistent medication administration. The anxiety prescription was noted as “pending delivery,” with follow-up calls documented. According to MAR, there were no missed doses of other routine medications. This agency has investigated allegations above. We have found that the above allegations were unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview conducted, a copy of this report provided.

On 07/03/2025 at 9:55 AM, Licensing Program Analyst (LPA) Ardalan Gharachorloo arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director, Parveen Singh and explained the purpose of the visit. LPA toured the facility including but not limited to 6 residents’ apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 71 degrees F. The hot water temperature in a residents bathroom was measured at 106 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 06/29/2025. Emergency Disaster Plan was last posted on 05/16/2025. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 05/22/2025. LPA reviewed 5 residents records and 5 staff records, and all were complete. LPA also reviewed a sample of 6 resident’s medications. The following documents were reviewed during the visit: LIC 500 Personnel Report LIC 610E Emergency Disaster Plan, Liability Insurance ,and Current Administrator’s Certificate. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

On 07/23/2024 at 10:21 AM, Licensing Program Analyst (LPA) Ardalan Gharachorloo arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Katherine Maningding and explained the purpose of the visit. LPA toured the facility including but not limited to 5 residents’ apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 72 degrees F. The hot water temperature in a residents’ shared and private bathrooms were measured at 111.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 06/30/2024. Emergency Disaster Plan was last posted on 07/18/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 06/11/2024. LPA reviewed 5 residents records and 6 staff records, and all were complete. At 11:42 AM, LPA also reviewed a sample of resident’s medications and medications log in the medications room. At 12:25 PM, LPA reviewed the following documents: LIC 308 Designation of Administrative Responsibility, LIC 500 Personnel Report, LIC 610E Emergency Disaster Plan, Liability Insurance, and Current Administrator’s Certificate. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

Allegation: Staff do not ensure facility is maintained odorless: Unsubstantiated LPA observed in memory care unit there is no odor smell. LPA observed in R1, R2, R3, R4, R5, and R6 room are kept clean and odor free. LPA interview S1, S2, and S3 stated that there has not been any odor that they notice in the building or in any resident’s room. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview conducted and a copy of this report provided via email.

Page 2 Allegation: Resident (R1) was not ambulated by staff as required. LPA interviewed 5 staff. One (1) out of 5 staff stated that R1's physical therapist wanted R1 to be walked but sometimes R1 refused. Four of the 5 staff stated they assist residents in walking, however, there are times when residents refuse. One the 5 staff stated she never walk resident if resident came from rehab or Skilled Nursing Facility and resident has broken bones. LPA interviewed R1's personal caregiver who stated she never observed staff walked R1. The personal caregiver of other resident was also interviewed who stated that when she needs help in assisting the resident she's hired for, the caregiver assists. Three out of 4 residents interviewed stated they can walk on their own. LPA was not able to get information from R1. Based on information gathered and LPA unable to obtain information from R1, the allegation of R1 was not ambulated by staff as required is closed as unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. .......continued on 9099C (page 3) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Page 3 Allegation: Facility failed to meet resident’s care needs. It was alleged that resident (R1) was not kept clean and left in wet, soiled diapers. The reporting party further stated that R1 was observed in soiled clothing and left in wet diapers on multiple occasions. LPA interviewed 5 staff, 4 residents, two personal caregivers and R1's family member on 10/06/21 and 8/24/23. One (1) out of 5 staff stated there were times she comes to the facility and observed residents in soiled clothing and wet diapers. One of the personal caregivers stated she observed R1 twice in soiled clothing and wet diaper, while the other personal caregiver stated she never observed the resident she's assisting and other residents in soiled clothing or wet. Four of the residents interviewed stated its either they don't need assistance in changing clothes and diaper while 1 stated the personal caregiver assist. The 3 residents stated they never observed other residents soiled and/or wet. R1's family member stated she never observed R1 in soiled clothing or wet diaper. During one of the visits, although LPA was not able to obtain information from R1, LPA observed R1 with no smell of urine and R1's clothing clean. Based on information gathered and LPA unable to obtain information from R1, the allegation of facility failed to meet resident’s care needs is closed as unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiency cited. Exit interview conducted, and copy of this report provided.

Allegation: Resident fell while in care Investigation Finding: Unsubstantiated Continuation... On 01/30/22, four staff assisted R1 walk to the bathroom. Later that day, R1 had an unwitnessed fall and required a 6 person assist to lift him up from the floor and put him to a chair. Review of R1’s progress notes show staff conducted frequent safety checks on R1 and called paramedics multiple times for R1’s lift assist. Based on interviews and record reviews which were conducted, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that resident fell while in care implying lack of care and supervision by staff is unsubstantiated. Exit interview conducted and a copy of this report provided. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation: Unlawful eviction Investigation Finding: Unfounded Continuation... On 02/03/22, staff (ALD, SED) held a care conference with R1’s authorized representatives (POAs) to discuss R1’s change in condition and new care plan with home health physical therapy visits. On 08/17/23, LPA observed R1 still resides at the facility during visit. This department had investigated the complaint alleging unlawful eviction. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis. Allegation: Facility did not provide resident 30-day notice Investigation Finding: Unfounded During investigation, staff (ED) confirmed with LPA that resident (R1) was never evicted. Therefore, there was no 30-day notice issued to R1. On 08/17/23, LPA observed R1 still resides at the facility during visit. This department have investigated the complaint alleging facility did not provide resident 30-day notice. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis. No deficiencies cited. Exit Interview conducted and a copy of this report provided.