Carefield Castro Valley

On 07/28/2021 at 9:51am, Licensing Program Analyst (LPA) A. O'Hollaren arrived unannounced to conduct Infection Control Inspection. LPA met with Administrator Parveen Singh and explained the purpose of the visit. During the inspection, LPA toured facility including but not limited to common areas, hand washing stations, bedrooms in Assisted Living and Memory Care, kitchen and backyard. LPA observed COVID-19 signage throughout the facility. Hand washing signs were posted at hand washing stations. LPA observed PPE, food and paper supplies are sufficient. COVID-19 screening questions were maintained at the facility for all staff, residents, and visitors. Hand sanitizer is provided at facility entryway. Common areas are disinfected frequently throughout the day. Carbon monoxide and smoke detectors were working. During record review, LPA observed facility has a copy of Mitigation Plan on file. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

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.

Allegation: Facility failed to meet the resident's needs. Unsubstantiated It was alleged facility failed to meet the resident’s needs, however, the department conducted staff interviews, reviewed R1’s assessments, and the care plan shows R1 does not need a one-on-one for all three R1 assessments, dated 10/2/2021, 2/17/2022, and 8/25/2022. However, R1 was to have 4 to 8 status checks per shift by a caregiver. After this incident, S3, S2, and S1 all decided to "have more eyes" on R1. "Having more eyes" means checking on R1 more. S6 told caregivers to watch R1 and R1's behavior. After R1 falls and R1 comes back from the hospital, the staff would monitor R1 more frequently and follow R1's discharge instructions During safety checks on R1, S9 would "pop in" the R1 room. Check to see if R1 was breathing or sitting. Checks were quick and lasted about two minutes. For the PM shift, S9 checks on residents about three to four times. S9 would always check on R1 before S9 left. Checks are not being documented. On 3/22/23 S6, S7, and S9 stated R1 refused to get change and bathing most time, and when R1 does want assistance, it depend on R1 mood. However, most time R1 doesn’t want to get assistant with ADL because to R1, R1 think R1 can still manage by R1 that R1 is still independent. Conducted interviews with S1, S2, S3, S4, S6, S7, S8, S9, S10, and HHN stated R1 is being checked 4 to 8 times, and always with a staff member. Report continues on KIC 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 Allegation: Lack of care resulted in resident sustaining multiple urinary tract infections. Unsubstantiated On 6/18/2021, R1 was admitted to the assisted living side of Carefield Castro Valley. R1 had been in and out of the hospital during R1's time at the facility. R1 was transported to Kaiser in San Leandro in January 2022, due to urinary tract infection (UTI), followed by COVID-19, and low platelets. Records reviews R1’s contacted UTI on 1/17/2022, 7/13/2022, and 8/23/22. However, before the three different events that R1 contracted, UTI S1 had requested R1 to get a check-up. S1, S6, S7, S8, and S9 encouraged R1 to drink more water, but R1 asked to be left alone. Staff stated they cannot force anyone to do anything they don’t want; they can only encourage. 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 are 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 Based on interviews of staff at the Carefield Castro Valley facility, R1 was admitted on 6/18/2021 and was transferred from the Assisted Living side of the facility to the Memory Care side on 2/18/2022 because of R1’s dementia diagnosis and a recommendation from Kaiser Memory Care Clinic for R1 to be in Care. Memory Care staff and documents show a history of seven falls from 5/4/2022 to 8/17/2022. Staff statements show R1 was considered a fall risk and that R1’s condition had changed both mentally and physically. Staff statements confirmed that R1 believed R1 could stand up and walk without assistance, however, R1 would fall and sustain multiple unwitnessed falls while being in R1’s room. Staff were aware to frequently check on R1, however, R1 fell multiple times. S1 stated S1 would keep R1 with S1 while working because S1 wanted to keep a closer eye on R1, however, the evidence does not show S1 gave any instructions to direct care staff to provide care and supervision to R1 to prevent R1 from falling in R1 room. Although facility staff were aware of R1's multiple falls, they failed to take adequate measures to ensure R1’s safety, resulting in multiple falls and/or being found on the floor in R1's room. R1 was sent by the facility to Kaiser on 5/4/2022, 7/11/2022, 7/13/2022 (twice), 8/17/2022, and 8/23/2022. R1 was diagnosed with fractured ribs on 7/13/2022 and a fracture to the T9-T10 vertebrae on 8/17/2022. Based on evidence obtained during the course of this investigation, the Department has determined that lack of supervision resulted in resident sustaining multiple fractures from unwitnessed falls. This is a factual determination based on all the facts and circumstances of the case. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED . Exit interview conducted. Appeal Rights and a copy of this report are 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.

LPA conducted interview with the resident (R1), during the interview resident stated that he does not remember any incident of staff leaving resident unattended. R1 stated that staff are assisting him all the time and always checking on him. Although the allegation may have happened or are valid, there are not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided to Executive Director.

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.

On 1/12/23 at 3:40PM, Licensing Program Analyst (LPA) C. Lin conducted an unannounced case management visit as a result of receiving residents from Grand Lake Gardens (GLG) and check on residents. LPA met with Resident Care Coordinator and explained the purpose of the visit. A total of 1 resident from GLG is currently living in CareField. During visit, LPA interviewed this resident who moved in on 12/14/22. The resident stated that she feels safe living here, staff are very nice to make her comfortable. Supplies were adequate and staffing is stable. There was no imminent health/safety concerns on today's date. Exit interview conducted with Resident Care Coordinator and a copy of this report provided.

On 9/15/22 at 1:49pm, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct Infection Control Inspection. LPA met with Parveen Singh Senior Executive Director and explained the purpose of the visit. During the Infection Control Inspection, LPA toured facility including but not limited to front entrance, screening station, hand washing stations, residents apartment, activities room, common areas, kitchen and courtyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. Visitors policy is posted on the front entrance. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has a mitigation plan and maintains record of routine screening for residents and staff. During record review, LPAs reviewed a sample of 6 staff records and observed 6 of 6 have health screening with TB test on file. Report continue on LIC 809C... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 9/30/22: LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Liability Insurance Current Administrator’s Certificate No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

On 8/25/2022 starting at 12:42 PM, Licensing Program Analysts (LPAs) K. Nguyen and L. Francisco conducted a Health & Safety inspection as a result of a priority 2 complaint. LPAs met with Parveen Singh, Executive Director. LPAs toured memory care facility with Resident Care Director including but not limited to the bathrooms, common areas, kitchen, and outdoor area. Hot water temperature was measured at 114 degrees F in the resident’s bathroom. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Refrigerator temperature was observed at 35 degrees F. Resident's medications were kept locked in the med room. Smoke detectors are interconnected with the sprinkler system. Carbon monoxide detector was observed. Fire extinguisher was observed to be fully charge. There are no accessible bodies of water observed. Indoor and outdoor passageways are free of obstruction. Facility appear to be safe and there are no imminent health/safety concerns on today's date. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided to Senior Executive Director.