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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced case management visit regarding an incident report, regarding a death report for a resident referred to as R1. LPA met with Administrator Rosalie B Zbasnik-Hulog and explained the purpose of the visit. On March 4, 2026, the Department received an incident report stating on March 3, 2026, stating resident R1 had passed away. The incident report stated on March 3, 2026 at 6:10pm, Wellness staff received a phone call from R1's family member, stating he/she has been calling R1, but no answer. Wellness staff went to the room and found R1 unresponsive. LPA requested R1's Identification and Emergency Information, house keeping schedule, physician's report, pre admission appraisal, medication list. LPA requested a copy of resident R1's death certificate once it becomes available. At this time, this case in under review and Department will conduct a follow visit , if warranted. No deficiencies cited during today's visit. This report was reviewed with Administrator Rosalie B Zbasnik-Hulog and a copy of the report was provided.

Resident is not being assessed for injuries after fall: Facility staff left resident on the floor after calling 911: On 10/01/2025, LPA interviewed Director of Health Service (DHS) Rosalie Hulog and Memory Care Manager. Both stated the facility policy is that caregivers are not allowed to move residents when they find residents were on the floor. The caregivers need to call nurses first (if nurse is busy, caregivers need to call Med Tech to come). Both stated the nurses check/evaluate resident on the floor and call 911 immediately. Both stated nurses check resident visually only. Both stated nurses cannot move the residents on the floor until paramedics come on site to evaluate the residents. Both stated nurses check if resident on the floor painful, bleeding, and check the vital signs. Both stated the nurses need to prepare the resident's document and to answer the questions from paramedics to help residents to be sent to hospitals. Both stated the policy was instructed to staff during the staff training. ON 10/01/2025, LPA interviewed the facility staff LVN (S1). S1 stated on 9/22/2025, he/she was notified by a caregiver that memory care unit resident R1 was found on the floor in R1's bedroom. S1 stated he/she went on site of R1's bedroom. S1 stated he/she called 911, evaluated R1 and prepared R1's document to be sent to hospital. S1 stated the facility's policy is not to move residents who are found on the floor. S1 stated another caregiver S2 was with him/her on site to take care and monitor R1. LPA interviewed caregiver S2. S2 stated he/she was notified on the floor in R1's room by another caregiver. S2 stated when he/she was on site at R1's room, S1 already there. S2 stated he/she observed S1 assessed R1 and prepared R1's document for the emergency room. S2 stated R1 stated he/she was fine but legs were numbed. S2 stated the facility policy is not to move residents who are found on the floor. Based on the review of the incident report dated 9/2325, R1's vital signs were 120/57 for blood pressure, 98.2 for temperature, 80 for pulse, 18 for respiratory rate, and 98% for oxygen. Based on the review of the facility policy of fall, it specifies do not move or lift an individual off the ground until it's verbalized that there's no pain and able to get up with minimum support and able to bear weight and ambulate. 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 The Department has investigated the above allegation. Based on the interview and record reviewed, 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 citation noted today. Exit interview was conducted with DHS. The report was provided to DHS for signature. A copy of the report was provided to DHS. Page 3 of 3.

L icensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit. LPA Rai met with Assistant Executive Director, Mark Nelson and Administrator, Rosalie Zbasnik/Hulog and stated the purpose of today's visit. During visit, LPA Rai toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas. LPA observed additional food supply areas and secured areas for cleaning supplies and laundry detergents. LPA Rai toured the facility to include at random 10 resident rooms. 10 Out of 10 resident bedrooms had available bedding, drawers, and functioning lights.  The facility bathroom had available soap, paper towels, and trash cans with lids. The hot water temperature in the bathroom sink ranged from 109.9 - 118.1 degrees F. Facility smoke detectors and sprinklers were in working condition and inspected by a third party vendor on 4/23/2024 and 5/8/2025. The last disaster drills were conducted on 7/4/2025 and 7/22/2025. LPA Rai reviewed facility records for 10 staff and 10 residents. LPA Rai reviewed resident medications and central stored medication records. Continuation on LIC 809-C, 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 Page 2 of 2. During visit, LPA Rai discussed a 90-day Eviction Notice for resident (R1). Administrator, Rosalie stated the family has been issued the letter on 07/16/2025 and the family is working with the facility's social worker as R1 requires higher level of care. LPA Rai reviewed the 90-day Eviction Notice and the letter is compliant with CCR 87224 Eviction Procedures. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Assistant Executive Director, Mark Nelson and Administrator, Rosalie Zbasnik/Hulog and a copy of the report was provided. LIC 858 and LIC 859 were provided.