1440 by the Bay

On 10/5/22 at 9:10AM, Licensing Program Analyst (LPA) C. Lin conducted an unannounced case management visit as a result of receiving self-reported incident dated 09/29/22 submitted to CCLD regarding resident sustained injury while in care. LPA explained the purpose of the visit with administrator (ADM). Upon entry, LPA went up to the 3rd floor and tested the egress door. LPA observed that the egress door alarm went off 30 seconds before opened when being pushed, and the alarm was loud enough to be heard throughout the building. ADM investigated the incident and stated that staff didn't respond timely when the alarm going off that resulted the resident in wheelchair was able to exit out to the stairway, wheeled down the stairway from the 3rd floor to the middle session where between the 3rd and 2nd floor, and injured. ADM stated that the responsible staff was suspended immediately after the incident occurred. Suspension letter from HR was provided. At a later time, ADM stated that the responsible staff was terminated as of today. LPA observed that the subject resident's most resent physician's report (LIC602) was dated on 11/18/2019. During visit, LPA randomly reviewed 3 memory care residents' LIC602 and observed that 2 out of 3 LIC602 were not updated yearly. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809 D. Failure to submit proofs of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties . A $500 immediately Civil Penalties is assessed on this day. Civil penalty determination related to serious bodily injury is pending. Exit interview conducted with ADM. LIC809D, LIC421M, Appeal Rights, and a copy of this report provided.

On 06/24/21 at 2PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted a Health and Safety check as a result of the department receiving a priority 2 complaint. LPA explained the reason for the visit with the HR Director and the Regional Director. During the health and safety check, LPA observed 14 staff wearing face masks. A universal entry station with routine COVID-19 symptom screening was observed in the front lobby. All staff, visitors and residents are required to electronically sign in, answer COVID-19 screening questions and complete the digital temperature scan. LPA toured facility with regional director, including but not limited to bedrooms, kitchen, bathroom, and common areas. Six memory care residents were observed engaged in reading activities in the recreation room assisted by 3 staff wearing face masks in the memory care unit on the 2nd floor. Other 5 residents in assisted living on the 3rd floor were observed relaxing inside their bedrooms. Residents in care appear to be safe and there are no imminent health/safety concerns on today's date. No deficiencies cited during the health and safety check. Exit interview conducted and a copy of this report provided.

Continued from LIC9099 Staff have made every effort to reasonably accommodate all residents' transportation needs. Resident have the option of booking their own transportation and paying out of pocket or utilizing the facilities van service. Based on interviews and record reviews conducted, the above allegation is 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 allegation is unsubstantiated. No deficiencies cited during visit. Exit interview was conducted, and a copy of this report was provided.

R1 was diagnosed with nontraumatic intracranial hemorrhage, hypertension, macrocytic anemia, history of Cerebrovascular Accident (CVA), dementia and seizure. However, R1 death certificate indicated her causes of death were cardiopulmonary arrest, myocardial infarction and hypertension. There were no other contributing factors to R1 death. A manner of death was not indicated. Allegation: Resident sustained injuries while in care: Unsubstantiated On 3/15/2023, The department reviewed record of R1 care notes and interview RP, and staffs indicate that R1 was sent to the hospital for evaluation. RP stated “While coming on to a Zoom meeting with Verna on 10/27/2020, RP daughter noticed and obvious bruise under R1 right eye. Staff did not report anything to R1 daughter prior to the Zoom meeting and did not know how R1 sustained the bruise”. During staff interviews, caregivers and med techs recalled R1 having a bruise, but vaguely recalled what happened after it was observed. Staff did not know how R1 sustained the bruise. Depending on the severity of an injury, residents are sent out to the hospital for further evaluation. Staff stated family members can always decline to have the resident transported to the hospital. During R1 hospitalization, R1 was diagnosed with a nontraumatic intracranial hemorrhage, dementia and seizure. Report Continue on LIC 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: Facility did not provide resident's records to responsible party. Unsubstantiated On 3/15/2023, The department interview R1 daughter indicated that recorded requested for R1 medical records and R1 file are all on the text messages that are being submitted to CCLD department. The department reviewed record of R1 daughter text messages, but didn’t not find that either R1 medical record and R1 files was being requested. However, there was a request of x-ray being requested by R1 daughter. Based on interviews and record reviews conducted, the above allegations are 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 was conducted and a copy of this report was 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: Staff did not seek medical attention in a timely manner- Substantiated On 3/15/2023, The department reviewed record of R1 including medical record, care note, facility’s protocol, and interview staff. The facility's protocol for residents sustaining a fall or an injury, if severe enough, are automatically sent out to the hospital for an evaluation. Because memory care residents are unable to verbalize whether they have fallen, in pain or injured themselves, there could be underlying issues after they sustained a fall or injury that cannot be seen with the naked eye. Despite the decision to transport the resident to the hospital, their families or responsible party can always decline medical transport. Caregiver recalled seeing R1 bruise and reporting it to the med tech. Caregiver was not positive, but believed R1 was sent to the hospital two days later to have it looked at. Program Director did not recall R1 bruise. After being shown photos of it, Program director confirmed that it was definitely a bruise and staff should have immediately sent R1 to the hospital to be evaluated. Caregiver remembered seeing the bruise on R1 eye and reported it to the med techs, but she did not know what was done after the fact. Report Continue on LIC 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 According to text messages between R1 daughter and the second-floor med tech (names unknown) between 10/28/2020 through 10/31/2020, the med tech was told to send R1 to the Emergency Department (ED) if the bruise worsened, per R1 doctor, Dr. Artemio Perez. On 10/29/2020, the med tech on duty advised they would send R1 out to the ED or request an x-ray if the bruise worsened. Dr. Perez ordered x-rays to be done, but it did not appear they were as R1 daughter inquired about it and there was no response by staff via text message. There were no records of an x-ray done and R1 did not go to the ER until 11/6/2020, approximately 10 days after the bruise was first observed. Based on evidence obtained during the course of this investigation, the Department has substantiated staff did not seek medical attention in timely manner. 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 provided.

On 10/06/2024 at 10:00 PM, Licensing Program Analysts (LPAs) David Doidge and Andrew Christy arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Executive Director Robert Alverado and explained the purpose of the visit. LPAs toured the facility including but not limited to, resident rooms, bathrooms, multiple activity rooms, kitchen, and common areas. LPAs observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 72 degrees Fahrenheit. The hot water temperature in a common bathroom was measured at 116.4 degrees Fahrenheit. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps 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 03/05/2025. Emergency disaster drills are conducted quarterly; last conducted on 10/01/2025. First aid kit was observed to be complete. LPAs reviewed five (5) resident records and five (5) staff records, all were complete. No deficiencies observed or cited during this visit. Exit interview conducted and a copy of this report provided

...Continued from LIC9099 On the allegation Residents are being mishandled. Interviews with staff and residents indicated that staff does not mishandle residents while in care. Staff or residents have not seen any staff mishandle residents. On the allegation Residents developing bedsores while in care. LPA was given a list of all of the residents who are bedridden and a list of residents who have bedsores. S1 stated that all of the residents with bedsores are bedridden and on Hospice. Based upon the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided.

On 11/20/2024 at 01:30 PM, Licensing Program Analysts (LPAs) D. Doidge and C. Fowler arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with, Stephanie Hall, Executive Director and explained the purpose of the visit. LPAs toured the facility including but not limit to, bedrooms, bathrooms, multiple activity rooms, kitchen, and common area. LPAs observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 72 degrees Fahrenheit. The hot water temperature in a common bathroom was measured at 107.1 degrees Fahrenheit. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps 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 01/15/2024. Emergency disaster drill was last conducted on 10/20/2024. First aid kit was observed to be complete. LPAs reviewed five (5) resident records and five (5) staff records, all were complete. No deficiencies observed or cited during this visit. . Exit interview conducted and a copy of this report provided

While at the facility, R1 tested positive for Covid. Staff interviewed state all the care needed including but not limited to assistance with ADLs as indicated in the assessment, housekeeping/changing of sheets once a week were provided. Staff state they wore full PPEs when going inside R1’s room to make sure care is provided. Regarding R1’s meal during isolation, staff interviewed state that dining staff would bring all of R1’s foods and leave them outside R1’s room. Then the caregivers would bring the food inside R1’s room wearing full PPEs. In regard to the privacy allegation, LPA interviewed S3. S3 states that while waiting for one of R1’s medicines that was ordered, a package was delivered. Thinking that it was R1’s medicine, S3 states that S3 opened the package. When S3 found out that it was not the medicine, S3 went to R1 and apologized. S3 states that R1 seemed fine and appreciated everything that the staff do for R1. LPA attempted to contact Reporting Party (RP) multiple times and left voice messages to obtain additional information and clarification regarding employee training. LPA did not get any call back from RP. Based on interviews and record reviews conducted, the above allegations are 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. No deficiencies were noted. Exit interview was conducted with the Hendricks and a copy of this report was provided.

LPA toured the facility’s secured memory care unit on the second floor and observed the following: secured entrance with code or key fob activation required for access, thermostat reading at 73 deg F in common carpeted hallways, large TV room with carpeted floors, 30 plus chairs for residents to use, 2 activity rooms with arts/crafts and storage cubes, inside garden with patio umbrellas, tables/ chairs, dining room with tables/chairs and big windows with sliders. The private room temporarily used by R1 in memory care was observed to be unlocked, have hard wood floors with a private full bath (toilet and shower stall with several handicap grab bars on walls, shower chair & towel holders), 2 wooden armoires, big window with sliders, independent air conditioner attached to the left upper wall with an accessible remote controller and kitchen sink with storage cabinets. ED stated rooms come unfurnished and residents bring their own furniture to use in their apartments. LPA observed the facility to be clean, odor free and in good repair. LPA observed 8 staff on the floor assisting 14 memory care residents who were comfortable in their surroundings during visit. 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 was not provided adequate living conditions while in care is unsubstantiated. Exit interview conducted and a copy of this report provided.

(...Continued from LIC9099) Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did occur; therefore, the allegations are UNSUBSTANTIATED . Exit interview conducted and a copy of this report provided via email.

Facility is threatening resident while in care. Based on interview with staff and residents. The staff denied threatening the residents in care, staff denied hearing or witnessing any staff threatening the residents in care. Based on residents’ interview, residents denied feeling threatened by staff, residents also denied hearing any staff threatened any residents in care. Resident is being emotionally abused while in care. It was alleged resident (R1) is being emotionally abused while in care. Based on interview with 6 staff and 2 residents, 6 of 6 staff and 2 of 2 residents denied allegation . Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are unsubstantiated. No deficiencies cited. Exit Interview conducted and a copy of this report provided to Administrator.

On 09/11/2023 at Licensing Program Analyst (LPA) L. Alexander conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 09/08/2023. LPA met with Executive Director, Stephanie Hall, and explained the purpose of the visit. Stephanie had copies of pertinent documents relevant to this incident. Stephanie says that there wasn't any witnesses to this incident. Stephanie will Stephanie stated that the suspect was recently hired at Elegance at Berkeley, 2100 San Pablo Ave, Berkeley, CA. Per Stephanie, supposedly the suspect is working as a private caregiver in general. LPA L. Alexander collected documents pertinent to the incident report. Documents received: Suspect's Personnel File Emails from victim's daughter Emeryville Police Dept Report# 2309-0449 No deficiencies issued during the visit. Exit interview conducted and a copy of this report was provided.

Continued from LIC9099 Investigation Findings: It was reported to the department that a resident feels isolated from peer group. LPA met R1 in the lobby by R1’s self. LPA overserved other residents keeping their distance and not making eye contact with R1 as LPA and R1 walked through the lobby. LPA interviewed R1 who expressed concerns about other residents avoiding R1 which makes making friends and socializing difficult. R1 feels cut off from others and that staff do not encourage socializing amongst residents. R1 was seen by staff returning to R1’s room after speaking with LPA. LPA spoke with S1 who informed LPA that R1 is in Independent Living and tends to keep to R1’s self. S1 stated R1 is able to leave the facility unassisted and will make trips to local stores a few times a week, alone. S1 and S2 have multiple times encouraged R1 to join group activities and have suggested different events for R1 to join. Neither have ever seen R1 show interest nor attend. S2 reported that R1 is not unconfrontational nor rude but does seem to avoid talking to others. S2 noted R1 is quiet and stays to self. LPA observed activity calendars with multiple events taking place throughout the day. LPA asked R1 if any seemed interesting. R1 said none did. Based on interviews and record reviews conducted, the above allegation is 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 and a copy this report was provided.

On 12/13/2022, Licensing Program Analyst (LPA) C. Lin conducted an unannounced case management health & safety check during the course of investigation. LPA met with Administrator and explained the purpose of the visit. LPA was screened at the front entrance with routine COVID-19 symptom and temperature checks done. LPA toured the facility with ED. LPA observed facility had sufficient food supplies in the kitchen. LPA also observed extra water supplies located in the garage. LPA observed Cough/sneeze etiquette and hand washing posters were posted in common areas and bathrooms. LPA observed dining area has been expanded to give additional seating choices for residents with tables six feet apart for social distancing. Staff was observed wearing surgical masks. Pathways and hallways were observed free of obstruction and fire hazards. There was no imminent health/safety concerns on today's date. Exit interview conducted with Administrator and a copy of this report provided via email.

Allegation: Staff will not allow resident to go outside – unsubstantiated The Department has investigated this allegation and per interviews and record review and found that residents in memory care unit will not allow to go outside of facility without assisted which is in compliance. Allegation: Staff do not take resident on outing – unsubstantiated The Department has investigated this allegation and per interviews and record review and found that facility has posted activities schedules each month. Residents R1 and R2 stated that they went out to a pumpkin patch last week and were able to show pictures. Residents R3, R4, and R5 stated that there was a walking club to parks that they joined once a while. Allegation: Staff did not safeguard residents clothing – unsubstantiated The Department has investigated this allegation and per interviews and document review and found that resident’s (R1) clothing was missed before moving into facility, R2, R3, and R4 disagreed that facility staff didn’t safeguard clothing while living in facility. Although the allegations may have happened or is valid, there is not a preponderance of evidence to provide the alleged violations did occur, therefore the allegations are unsubstantiated. No deficiencies cited. Exit interview conducted with Executive Director and a copy of this report provided.

On 9/21/2022 starting at 1:10 p.m., Licensing Program Analyst (LPA) Catherine Lin arrived unannounced to conduct Infection Control Inspection. LPA met with Administrator and disclosed the purpose of the visit. Upon entry, LPA’s temperature was checked and asked to fill out Covid-19 questionnaire at Accushield, and requested to wash hands by staff. LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, bathrooms, kitchen, common areas, and outdoor areas. 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. Facility staff were observed to be wearing proper PPE. Facility has a sufficient 2-day perishable and one-week non-perishable food supply. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has Mitigation Plan, Emergency Disaster Plan, and maintains record of routine screening for residents, staff, and visitors. No deficiency cited during visit. Exit interview conducted with Administrator, and a copy of this report provided.

On 11/19/2021 starting at 12:09 PM, Licensing Program Analyst (LPA) C. Lin arrived unannounced to conduct Infection Control Inspection. LPA met with Agustin Samaniego, Executive Director (ED) and explained the purpose of the visit. Upon entry, LPA’s temperature was checked and completed Covid-19 questionnaire at Accushield, LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, bathrooms, kitchen, and common areas. 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. Hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a sufficient 2-day perishable and one-week non-perishable food supply. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has Mitigation Plan, Emergency Disaster Plan, and maintains record of routine screening for residents, staff, and visitors. No deficiency cited during visit. Exit interview conducted and a copy of this report provided.