Vista del Lago Memory Care.

INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Facility staff did not notify resident's representative of a medical procedure conducted on the resident. The complaint alleges that the staff at the facility did not inform Resident #1’s (R1) representative about a medical procedure that took place. Specifically, it states that on February 4, 2025, a biopsy was performed on (R1), which required two stitches on (R1’s) lower left back, as reported by the hospice nurse. Additionally, it is claimed that the facility administrator was unaware of this procedure. No further information regarding the allegation has been provided. On April 25, 2026, between 9:45 AM and 11:59 AM, the Department interviewed resident members identified as Resident #2 through Resident #9 (R2-R9). Eight (8) out of the (8) were unable to support this claim. (R2-R9) appreciated the staff and reported no issues with notifying their representative about medical treatments, procedures, or hospitalization. (R2) shared that staff member #1 (S1) showed kindness by visiting (R2) during a hospital treatment. (S1) offered support and brought personal items during this difficult time. Resident #1 (R1) was not available for an interview as the resident had passed on April 8, 2025. On April 25, 2026, between 8:40 AM and 3:35 PM, the Department interviewed staff members identified as Staff #1 through Staff #5 (S1-S5). Five (5) out of the five (5) staff members could not corroborate this allegation. Staff members (S1-S5) reported that they are responsible for notifying resident representatives about medical events or procedures. (S1, S2, and S5) stated that a resident's authorized representatives are informed whenever a medical procedure is performed or the resident's condition changes. Specific forms, logs, and communication tools are used for this purpose, including phone calls, voicemails, emails, and written notifications. Additionally, (S1 and S5) indicated that in the case of (R1), the biopsy treatment was performed by Mismo Dermatology, an in-house service provider, who worked with (R1's) authorized representatives to obtain authorization and consent for the treatment. On February 9, 2026, and April 25, 2026, between 03:30 PM and 04:30 PM, the Department attempted to interview witness members identified as Witness #1 through Witness #3. (W1) was interviewed but decided not to proceed, stating that they are no longer affiliated with Vista Del Lago Memory Care. (Evaluation Report continues LIC 9099-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 (W1) thinks that their past connection might not reflect the current situation and could have caused some issues. (W2-W3) were unavailable for interviews as calls went unanswered. The Department reviewed Resident #1 (R1's) service file which included the Miso Dermatology Authorization and Consent Form (date 07/16/24) it indicated "I hereby authorize and consent to any of the following operation(s) or procedure(s) as deemed medically necessary by the provider": biopsy, liquid nitrogen freezing, local anesthetics, phototherapy, complex wound excision, and other skin procedures. Representative authorization appears in the patient's signature dated 07/16/24. A review of the Consent for Emergency Medical Treatment, LIC 627 (dated 06/04/24) indicated that an authorized representative signed the form. Further review of (R1’s) Physicians Report LIC 602A (dated 05/06/24), Preplacement Appraisal Information LIC 603 (dated 05/30/24), Move In Record (dated 06/13/24), Physicians Order for Life Sustaining Treatment (dated 05/06/24), Declaration of Health Agent (dated 06/04/24), Comfort and Peace Records (dated 01/16/25), Facility Progress Notes (dated 02/5/25 & 02/07/25), Medication Administration Record (dated 02/01/25 through 02/28/25), Miso Dermatology Notes (dated 02/04/25) and Residence and Care Agreement (dated 06/04/24). Based on the information gathered, there is not enough evidence to support the allegation mentioned above. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. The allegation may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is Unsubstantiated . An exit interview was conducted with Brianna Garcia, and copies of the reports were provided.

INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Lack of staff supervision resulting in residents engaging in a physical altercation. The complaint alleges that a lack of supervision led to a physical altercation among residents. It has been reported that Resident #1 (R1) and Resident #2 (R2) were involved in an incident that resulted in (R1) being admitted to the hospital with a closed ankle fracture. Further reports indicate that the altercation occurred in (R1's) room after (R2) entered, resulting in a confrontation. No additional information regarding the allegation has been provided. On April 25, 2026, between 9:45 AM and 11:59 AM, the Department interviewed resident members identified as Resident #2 through Resident #9 (R2-R9). Eight (8) out of the (8) were unable to support this claim. (R2-R9) were all complimentary of the staff and expressed that they received adequate care, support and supervision in a responsive manner. (R2) could not recall the incident that occurred on June 08, 2025, with (R1) and denies having any physical altercations. (R2) stated to be on a friendly relationship with (R1). Resident #1 (R1) was not available for an interview as the resident is currently being treated at Santa Fe Post Acute and did not return calls. On April 25, 2026, between 8:40 AM and 3:35 PM, the Department interviewed staff members identified as Staff #1 through Staff #5 (S1-S5). Five (5) out of the five (5) staff members could not validate this allegation. Staff members (S1-S5) expressed care and supervision are priority for all staff. According to (S1-S5), there have been no prior verbal or physical altercations between Residents #1 (R1) and #2 (R2). Both residents are diagnosed with Major Neurocognitive Disorder (NCD) and exhibit behaviors associated with this condition. However, neither requires one-on-one care. (S5), who was present during the incident, reported that two other staff members, along with (R1) and (R2), immediately responded when they heard yelling and noises coming from (R1's) room. (S5) explained that (R2) wandered into (R1's) room, mistakenly thinking it was (R2’s) own room, and sought to use the bathroom. During this encounter, a verbal and physical altercation occurred, wherein (R1) grabbed (R2) by the arm, prompting (R2) to push (R1), who then fell to the floor. Following the incident, (R1) complained of leg pain and was taken to the hospital. (S1-S2) disputed claims of a lack of supervision, emphasizing that the facility has adequate staffing, trained personnel, immediate communication via walkie-talkies, and surveillance cameras in place. (S1) detailed the staffing for different shifts: the morning (AM) shift consists of five caregivers, two med-techs, and one nurse; the afternoon (PM) shift includes five caregivers, two med-techs, and one nurse; while the evening (NOC) shift has four caregivers and one med-tech. (Evaluation Report continues LIC 9099-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 (S1-S2) outlined their plan for handling staffing shortages, call-outs, and schedule changes affecting supervision. Staff must secure their own coverage when they call out, and any staffing emergencies are managed through agencies like Clipboard Health. Furthermore, all staff members (S1-S5) have confirmed completion of the required 40 hours of in-service and hands-on shadow training related to (NCD). On April 25, 2026, between 9:30 AM and 04:30 PM, the Department attempted to interview witness members identified as Witness #1 (W1). (W1) was unavailable for an interview as calls went unanswered. The Department reviewed Resident #1 (R1’s) service file which included Physicians Report LIC 602A (dated 09/23/23) Service Plan Report (dated 06/16/25), Medication Administration Record (dated 02/01/25 through 02/28/25), Residence and Care Agreement (dated 06/04/24), Move In Record (dated 06/16/25), Palomar Medical Records (dated 06/09/25) and Unusual Incident/Injury Report LIC 624 (dated 06/11/25 and it revealed that (R1) is medically evaluated with occasional agitation behavior. Further review of Resident #2 (R2’s) service file included Physicians Report LIC 602A (dated 06/03/25) Resident Appraisal LIC 603A (dated 06/06/24), Residence and Care Agreement (dated 06/17/24), Move In Record (dated 06/16/24), Unusual Incident/Injury Report LIC 624 (dated 06/11/25 and it revealed that (R2) is medically evaluated with wandering behavior and no aggressive behavior. Additional analysis of personnel Care Staff Assignments (dated 06/08/25), Personnel Report LIC 500 (dated 04/25/26) and Relias In-Service Training (dated 01/15/26, 02/19/26, 02/20/26 and 04/24/26) revealed confirmation of number of personnel for each work shift and completed mandatory training requirements. During the visit on April 25 and 26, 2026, the Department identified that the facility promotes the rights and safety of its residents. Posters outlining Resident Rights, Personal Rights, and the California Residential Care Facilities for the Elderly Complaint Poster were displayed prominently throughout the facility. Based on the information gathered, there is not enough evidence to support the allegation mentioned above. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. The allegation may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is Unsubstantiated . An exit interview was conducted with Brianna Garcia , and copies of the reports were provided.

Allegation #1: Staff did not seek medical treatment for the residents. The complaint alleged that staff contacted the responsible party after discovering residents in the facility's hallway who were shaking, unable to walk, and disoriented, instead of calling the Medical Emergency Service (MES). On December 17, 2025, LPA Richard interviewed the Administrator (A1), who denied the allegations. A1 stated that the facility has strict protocols in place. According to A1, there is no way the staff would fail to call EMS when necessary, and they likely informed the responsible party (RP) about the residents' conditions. Additionally, LPA Richard interviewed the Memory Care Director (MDC) on the same day, who also denied the allegations. MDC affirmed that the facility is trained to call EMS in urgent situations, followed by contacting the nurse. LPA Richard also interviewed four staff members, #1-4 (S1 to S4), all of whom denied the allegations and emphasized that resident care and well-being are their main priorities. After assessing the situation, the staff felt that resident R1 was stable and did not see the need to call EMS. Later that day, LPA Richard interviewed six residents #2-7 (R2 to R7). Five of the six residents denied the claim that the facility wouldn’t call EMS when needed, noting that the facility had called EMS for them on numerous occasions. Report Continued on LIC9099C 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 Records reviewed the facility notes dated June 3, 2024, which indicated that the Responsible Party (RP) visited R1 while R1 was eating. During the visit, the RP observed that R1 was alert and oriented but could not answer questions about R1's feelings. The RP decided it was best to take R1 to the emergency room for further evaluation, leading to R1's hospitalization that day. At the same time, LPA reviewed R1's Physician List of Medications. R1 was prescribed Levothyroxine (Aricept) 10 MG Tablet; the side effects of this medication include dizziness and disorientation. On June 5, 2024, the facility called the RP, who indicated that R1 might be discharged that day. However, the Executive Director mentioned that R1 never returned to the facility after the hospitalization. The LPA was unable to interview R1, as R1 no longer resides at the facility. LPA Richard was unable to interview R1 because R1 moved out of the facility on 6/01/2024. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (S) did or did not occur; therefore, the allegation is Unsubstantiated. Report Continued on LIC9099C 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 #2: Staff do not intervene when a resident assaults another resident. The complaint alleged that some residents had confronted others, and the staff failed to intervene. On December 17, 2025, LPA Richard interviewed the Administrator (A1), who denied these allegations. A1 stated that the facility staff would intervene and redirect the residents as needed. According to A1, this is a memory care facility. Additionally, LPA Richard interviewed the Memory Care Director (MDC) on the same day, who also denied the allegations and affirmed that staff were trained to help redirect residents. LPA Richard conducted interviews with four staff members (S1-S4), all of whom denied the allegations. They emphasized that the facility's main priorities are resident care and well-being. The facility employs many staff members who are present on the floor with the residents. In the event of any altercation, these staff members are readily available to intervene, although such incidents are rare. Later that day, LPA Richard interviewed six residents (R2-R7). Five of the six residents denied the allegations and stated that the staff are always present to help redirect or assist the residents. During the visit, LPA Richard observed a significant number of staff on the floor engaging with the residents, participating in activities, watching TV, and conversing with one another. The LPA was unable to interview R1 because R1 moved out of the facility on 06/01/2024. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (S) did or did not occur; therefore, the allegation is Unsubstantiated. 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 allegation #3: Due to a lack of supervision, the residents had multiple falls. The complaint alleged that the residents had numerous falls due to the facility leaving the residents unsupervised. On December 17, 2025, LPA Richard interviewed the Administrator (A1), who denied these allegations. A1 stated that the facility staff had never reported that R1 had falls. The facility had a protocol for unwitnessed and witnessed falls. According to A1, the staff will call the Nurse, not move the resident, and make sure the resident is not in pain. Additionally, LPA Richard interviewed the Memory Care Director (MDC) on the same day, who also denied the allegations and affirmed that staff were trained on how to approach witness and unwitnessed falls. LPA Richard interviewed four staff members (S1-S4), all of whom denied the allegations. They emphasized that the facility's main priorities are resident care and well-being. They also stated they will call the nurse, ensure the resident is not in pain, and, if necessary, call EMS. Additionally, they mentioned that they checked residents' rooms every hour, with some being checked every half hour. Later that day, LPA Richard interviewed six residents (R2-R7). Five of these six residents denied the allegations and also stated that the facility checked their rooms every hour. On December 17, 2025, LPA records reviewed the facility notes dated April 17 and May 8, 2024, showed that during a room check, the staff member found R1 sitting on the floor of the R1 bedroom. The staff asked if R1 was in pain and said they would call 911, but R1 refused and wanted to go to Urgent Care. The facility then called RP, who stated that RP would come and take R1 to urgent care. 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 During the visit, LPA Richard observed many staff members on the floor engaging with residents, participating in activities, watching TV, and talking with one another. The LPA was unable to interview R1 because R1 moved out of the facility on 06/01/2024. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (S) did or did not occur; therefore, the allegation is Unsubstantiated. No deficiencies were cited. An exit interview was conducted, and a copy of the report was given to the Executive Director, Marie Hill.

The investigation revealed the following: Allegation: Staff did not notify responsible party of a resident's fall resulting in medical attention The detail of the complaint alleges that responsible party was not notified that R1 had fallen on 2/24/23. On 11/4/25, at 12:43 p.m., the Department interviewed the Executive Director (A1) who denied the allegation, stating that no fall was reported on 2/24/23. However, she confirmed that an unwitnessed fall did occur on 2/12/23, and that the responsible party was notified of the fall through an incident report. On 11/4/25, the Department obtained and reviewed an incident report concerning an unwitnessed fall that took place on 2/12/23. The report confirmed that appropriate notifications were made, including to the responsible party and the primary care physician. It further indicated that no head impact occurred, and no injuries were sustained. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; 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. 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 Allegation: Staff failed to administer resident's medications as prescribed The detail of the complaint alleges that R1’s medication was not refilled resulting in R1 missing medication. On 11/4/25, at 12:43 p.m., the Department interviewed Executive Director Marie Hill (A1), who denied the allegation, stating that there had been no report of R1 missing any medication. A1 stated that staff members are trained in medication administration and receive regular refresher training. A1 further described the facility’s process: “The doctor sends the orders to the pharmacy, where they are reviewed before being forwarded to us. We then check and double-check the orders to ensure accuracy.” On 11/5/25, between 10:00 a.m. and 12:00 p.m., the Department interviewed 6 residents (R2–R7). R1 has not resided at the facility since 10/25/24. 6 out of 6 residents reported that they consistently receive their medication on time and have never missed a dose due to staff error . On 11/6/25, the Department obtained, reviewed and evaluated R1’s Medication Administration Record (MAR) and Physicians orders for the month of November 2022 and found no discrepancies during the review period. Based on the information gathered there is insufficient evidence to support the allegation mentioned above; 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. There were no deficiencies cited during today's visit. Exit interview conducted and copy of report provided. Page 3 of 3

The investigation revealed the following: Allegation: Resident was admitted without consent of responsible person The detail of the complaint alleges that the resident nor his conservator sign the admission agreement. On November 4, 2025, at 12:43pm the Department interviewed Executive Director Marie Hill (A1) who denied the allegation stating the responsible party did sign the admission agreement. A1 further stated that the Residents do not sign because the facility is full memory care and they need their responsible party to sign. On November 4, 2025, between 1:00pm and 2:30pm, the Department interviewed 5 staff (S1-S5) regarding the allegation. Of those interviewed 5 out of 5 could not provide any input on this allegation because they are not part of the residents' admission agreement signing process. On November 4, 2025, the Department obtained and reviewed a copy of the R1’s admission agreement which revealed that the document was signed by the responsible party and the Executive Director. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; 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. Page 2 of 4 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 do not distribute medications according to physician’s orders. The detail of the complaint alleges that the staff doesn’t give R1 his medication on time. On November 4, 2025, at 12:43pm, the Department interviewed Marie Hill (A1) who denied the allegation stating that there has been no report of R1 missing medication. A1 further stated that her staff are trained on medication administration and have frequent refreshers. A1 states that “the facility get the orders from the doctor, it's sent to the pharmacy first and they check orders before it is sent to us. Then we check and double check the order to make sure it is correct.” On November 4, 2025, between 1:00pm and 2:30pm, the Department interviewed 5 staff (S1-S5) regarding the allegation. Of those interviewed 5 out of 5 denied allegation stating that R1’s medication was given on time and as directed by the doctor. 5 out of 5 staff state that they have had medication training. Lastly, 5 out of 5 state that missed medication is rare, but when it happens they report it to the doctor, the responsible party and to the Department via incident report. On November 5, 2025, between 10:00am and 12:00pm the Department interviewed 6 residents (R2-R7). R1 was not interviewed as R1 no longer lives at the facility as of 10/25/24. Of those interviewed 6 out of 6 stated that they receive their medication on time and they have never missed a dose due to staff not giving it. page 3 of 4 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 On November 4, 2025, the Department obtained, reviewed and evaluated R1’s Medication Administration Record (MAR) for the months of August-September 2023 and found no discrepancies during the review period. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; 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. There were no deficiencies cited during today's visit. Exit interview conducted and copy of report provided. Page 4 of 4

The investigation revealed the following: Allegation: Staff does not ensure resident dental care needs are being met The detail of the complaint alleges that the facility is not ensuring that R1 receives needed dental care. The Department interviewed Marie Hill Executive Director (A1) who denied the allegation, stating that R1 had received dental services while he lived in the facility. A1 stated that the responsible party signed the dental authorization form to agree to receive in house dental services where the Dental Hygienist or Dentist will provide services at the facility. A1 further stated that if the dental hygienist make a referral for services outside of the facility, then they typically discuss it with the resident's family so that arraignments could be made. Lastly, A1 stated on 4/17/23, R1 saw the Dental Hygienist who made a referral, however R1 declined the service because of the expense. On 11/5/25, the Department obtained and reviewed the Dental Hygienist report (dated 4/17/23) which corroborated the Executive Director (A1) assertion that R1 did receive dental services while at the facility. Additionally, the Dental Hygiene report showed that a referral for dental services was made, but R1 stated that it was too expensive; therefore, declining the referral. Lastly, the Department reviewed dental authorization (dated 7/11/22) signed by the responsible party accepting services for R1 to be seen by dental hygienist and dentist that comes out to the facility. Page 2 of 4 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 On 11/5/25, between 10:00am and 12:00pm, the Department interviewed 6 residents regarding dental services offered at the facility. 6 out of 6 stated that they are offered dental services; 4 out of 6 stated that a family member make appointments for them when needed and 2 out of 6 stated that they have dentures and doesn’t use any dental services. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; 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. Allegation: Staff do not assist resident with transportation to the dental office. The detail of the complaint alleges that “the facility does not transport R1 to the dental office, but rather a private dentist would come to the facility for all the residents.” The department interviewed Executive Director Marie Hill (A1) regarding this allegation. A1 stated, “Usually the family would transport residents to the dentist because the family needs to make decisions for the resident’s care. The facility is not authorized to make medical discussions so the family will have to be there at the dental office to make decisions for care.” On 11/5/25, the Department interviewed 6 residents regarding the allegation and of those interviewed 6 out of 6 stated that if they needed to see the dentist they would use the dentist on site, but if they needed outside services then family would transport them to the dentist. Page 3 of 4 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 the information gathered, there is insufficient evidence to support the allegation mentioned above; 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. There were no deficiencies cited during today’s visit Exit interview conducted and copy of report provided. Page 4 of 4

On 09/09/2025, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced visit to the facility for a required annual inspection. LPA met with Administrator, Marie Hill who was informed of the purpose of the visit. LPA toured the facility with Administrator Hill. The facility is made up of one (1) building designated for memory care. The facility is licensed for 96 non-ambulatory residents of which 10 may be bedridden. The facility also has an approved hospice waiver for 35 residents and LPA was informed there are currently 12 residents on hospice. The facility has an activity room, several dining areas, and outside shaded seating available for resident use. Indoor and outdoor passageways are free of obstruction. There are no bodies of water on the premises. LPA observed fire alarm systems, carbon monoxide detectors and charged fire extinguishers mounted throughout the building. LPA toured the kitchen and obseved the facility met Departmental requirements for a two-day supply of perishable foods and seven-day supply of non-perishable food items. Food is stored in a safe and healthful manner. Medications are stored inside medication carts in the locked medication room, which only accessible to authorized personnel such as medication technicians. Cleaning solutions are stored in the housekeepers' lockers that are secured with master locks inside the locked laundry room. Resident files reviewed had updated physician's reports and signed admission agreements. Staff files reviewed had the required records. LPA reviewed the facility's Fire/Internal Disaster Drill noting their last fire drill was conducted on 07/22/2025. Long Term Care Ombudsman's contact information, complaint procedures, resident's personal rights and emergency disaster plan were visibly posted near the front entrance. No deficiencies were issued during today's visit. An exit interview was conducted and a copy of this report was reviewed and provided to Administrator Hill.

still ambulatory and walked around and out of the facility without an assistive device. R1’s resident assessments, dated 01/23/2022 and 02/19/2023, both indicated a fall risk service plan with safety checks four times per shift and as needed for R1. A review of the medical records and facility nursing notes revealed that on 05/31/2022, R1 complained of pain in left arm and staff noticed slight swelling in R1’s left wrist. R1’s resident representative was immediately notified and R1 was sent to the hospital for evaluation. According to the medical records, the paramedics stated R1 was pushed off the bed by another resident and fell onto their outstretched arms; patient complained of bilateral wrist pain. X-rays revealed bilateral distal radius fractures. R1 was diagnosed with left and right wrist fractures with no surgery performed. The facility nursing notes, dated 05/31/2022, list “aggressive act victim; R1 noted to have limited range of motion to left arm, slight swelling noted to wrist, hand appears to have no swelling, wrist tender to touch….. Received update from hospital, R1 has fracture to left wrist”. Due to R1’s cognitive impairment, R1 was unable to explain how R1 injured their wrist. On 08/20/2022, R1 fell to the ground when R1 ran into another resident. R1 was evaluated by the facility med tech where R1 initially complained of pain in wrist and arm (nursing notes do not indicate which side). R1 had normal range of motion and stated, “my arm is not broken, if it was, I would be screaming my head off.” R1 was not sent out to the hospital and was treated at the facility with ice packs and monitored. No further complaints of pain were reported. On 11/20/2023, R1 complained of right wrist pain when staff were assisting R1 to get undressed for bed. There was no witnessed fall and R1 was not found on the floor. R1 was assessed and sent to the hospital to be evaluated. During R1’s examination, R1 had x-rays done on both shoulders and right wrist. The left shoulder showed no fractures. The right shoulder showed chronic appearing fractures. The right wrist showed chronic appearing deformity of the distal radius with positive ulnar variances. The bones are demineralized. No acute fracture is seen. The records indicated “chronic injuries that are well healing”. The hospital discharge paperwork, dated 11/21/2023, states “we will discharge the patient home with right wrist and right shoulder fractures which appear to be chronic with a plan for orthopedic follow-up and PCP follow-up”. The 11/21/2023 facility nursing notes revealed the hospital called to give update on R1 and stated R1 seen for right wrist pain had x-ray done on right wrist and shoulder and showed chronic fractures of right wrist and shoulder. 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 An interview with the physician who examined R1 at the hospital on 11/20/2023 was conducted. R1’s x-rays and medical history charts were reviewed. Although R1 did not show any new fractures during the visit, R1 had chronic appearing fractures in R1’s wrists, shoulders and ribs from other past visits. The physician said they could not determine the age of the chronic appearing fractures and they all appeared to be healed or healing. The physician said this and the fact that R1 came to the hospital from an assisted living facility with old trash bags concealed in R1’s pants gave concerns of neglect at the facilit y. The physician spoke with R1’s resident representative who informed the physician it is normal behavior for R1 to conceal items in R1’s clothing and it is part of R1’s diagnosed behavior. R1’s resident representative also told the physician that they believe the staff at the facility treat R1 well and has no concerns for R1’s care at the facility. During the course of the investigation, the Department was informed by R1’s resident representative that R1 suffered two falls before moving into Vista Del Lago, one at a board and care facility where R1 fractured left shoulder and left wrist, and one at home where R1 fractured several ribs. The physician stated that R1’s resident representative did not provide this history to them during their conversation, and it explains many of the chronic appearing fractures R1 showed during his examination. The Department’s investigation revealed facility staff acted appropriately during each incident and advised R1’s resident representative of R1’s condition and obtained R1 needed medical care. Since R1’s return from the hospital on 11/21/2023, staff have been directed to do increased safety checks, home health physical therapy has been ordered and the Resident Services Director said R1’s care plan will be reassessed once R1 is seen by R1’s physician. During the investigation, no evidence or statements were found to corroborate neglect or lack of supervision of R1. Therefore, the allegation is deemed Unsubstantiated at this time. 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(s) occurred. Exit interview conducted, copy of this report was reviewed and provide to Marie Hill, Executive Director.

LPA conducted an interview with the reporting party who reported the following information. Care Coordination Agencies (CCAs) collaborate with a resident, their responsible person and assisted living facility to enroll the resident onto the ALW program. Vista del Lago Business Office Director (BOD), Jennifer Rios verbally agreed to assume responsibility to assist R1 with ALW program enrollment. However, in fall 2024 BOD failed to follow up and provide requested information to R1’s CCA, which resulted in R1 losing their place in the ALW program waitlist. LPA conducted an interview with BOD Rios who refuted the allegations and reported the following information. BOD denied ever assuming responsibility to enroll R1 in the ALW program as it is outside of the scope of their duties. R1’s CCA requested resident records from the facility; however, the request was accidentally overlooked by facility staff and R1’s CCA/responsible person did not follow up on the request prior to R1 being dropped from the ALW program waitlist. Administrator Hill was also interviewed and reported the following information. Although the facility collaborates with CCAs/responsible persons and provides any requested resident records to aid in the ALW program enrollment, it is not the facility’s responsibility to enroll any resident in the ALW program. The facility is only responsible for providing care and supervision funded by ALW. Furthermore, the facility did not act with malice and there is no financial incentive to sabotage R1’s ALW program enrollment. Administrator Hill added they believe R1 receives the required care and supervision at the facility and the facility has never restricted R1 or any other resident from pursuing other housing options. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report and Confidential Names list (LIC 811) was reviewed and provided to Administrator Hill.

On 12/6/2024, Licensing Program Analyst (LPA), Janette Romero conducted an unannounced health and safety visit to the facility to follow up on an Unusual Incident/Injury Report (LIC 624) submitted to the Department reporting incidents that occurred in the facility on 11/29/2024, involving Resident 1, Resident 2, Resident 3 and Resident 4. PA met with Administrator, Marie Hill who was informed of the purpose of the visit. LPA toured the facility, reviewed and requested video footage, and copies of pertinent records. The requested documentation will be emailed to LPA by close of business on 12/9/2024. During the visit, LPA observed the facility has working utilities along with a two-day supply of perishable food and seven-day supply of non-perishable food items. No deficiencies were cited during today's visit. No imminent health or safety concerned were observed during the tour. An exit interview was conducted and a copy of this report was reviewed and provided to Administrator Hill.

On 12/6/2024, Licensing Program Analyst (LPA), Janette Romero conducted an unannounced health and safety visit to the facility to follow up on an Unusual Incident/Injury Report (LIC 624) submitted by facility to the Department reporting an incident on 12/2/2024 involving Resident 1. LPA met with Administrator, Marie Hill who was informed of the purpose of the visit. LPA toured the facility, conducted interviews, and requested records. The requested documentation will be emailed to LPA by close of business on 12/9/2024. During the tour, LPA observed the facility has working utilities along with a two-day supply of perishable food and seven-day supply of non-perishable food items. No deficiencies were cited during today's visit. No imminent health or safety concerns were observed. An exit interview was conducted and a copy of this report was reviewed and provided to Administrator Hill.

Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit . LPA was granted entry and met with Executive Director Marie Hill and Resident Service Director Priscilla Bermudas who was informed of the purpose of the visit. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following: Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. LPA observed a courtyard with outdoor furniture and shaded area for residents. Facility contained PPE equipment and cleaning supplies to do regular cleaning of the facility. Cleaning supplies, detergents, and the sharp and dangerous objects were locked and inaccessible to the residents in the facility's janitorial and maintenance supply rooms. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The smoke detector, carbon monoxide, and facility sprinkler system was operational and is maintained annually. Facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods. LPA was informed the facility receives multiple food deliveries a week. LPA reviewed four (4) staff files and training. All staff have the required personnel records on file and criminal record clearance and updated training along with CPR/First Aid Certification. Five (5) resident files were reviewed, and possessed all required paperwork which included Admissions Agreement, Needs and Service Plan, and Physician's Report. The listed administrator possesses a current administrator's certificate. 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 observed medications are kept locked and inaccessible to residents in the medication room. LPA observed a MedTech getting ready to conduct blood glucose test for two (2) residents. Staff document medication administration on the facility's electronic Medication Administration Record (eMAR). LPA observed Medications prescribed to residents and found all medication listed on eMARS and all required labeling was found to be in place. Facility has an updated emergency and disaster plan and Infection Control plan. LPA observed all facility exits were clear from obstructions. Facility has a working delayed egress system on the exit doors. LPA observed emergency supplies and first aid kit with all required items. Facility contained multiple charged fire extinguishers located throughout the facility. Facility conducts monthly disaster drills with the last drill being performed on 09/05/2024. No deficiencies were cited at the time of the visit. An exit interview was conducted where a copy of this report was provided to Executive Director Hill.

Interview with R1 reported they receive their insulin in the morning at 8am, in the afternoon at 12am, and in the evening at 4pm. Interview with Staff Two (S2) revealed R1 receives two types of insulin shots in the morning, one in the afternoon, and two types of insulin at dinner. S2 reported staff check R1’s glucose three times a day before administering insulin so R1 can receive the correct dosage of units/ml of insulin. This agency has investigated the complaint alleging “Staff failed to ensure resident's insulin orders were followed”. 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, and a copy of this report was provided to Executive Director Hill.

Interview with R1 revealed staff have been following physician’s orders and have been checking R1’s blood sugar every Monday. This agency has investigated the complaint alleging “Staff are not ensuring that insulin is being administered in a safe manner”. 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, and a copy of this report was provided to Executive Director Hill.

Licensing Program Analyst (LPA) Sara Martinez made an unannounced visit to the facility. The purpose of the visit was to conduct interviews with staff regarding a complaint that is related/associated with this facility. LPA was greeted and granted entry by Priscilla Bermudes Resident Services Director, where LPA explained the purpose of her visit. No heath and safety concerns were observed at the time of LPAs visit. An exit interview was conducted, and a copy of this report was reviewed and provided to Bermudes.

The medical professional also observed R1 was favoring the left side of their body due to a painful Stage II pressure injury located on their right heel. The Medical professional’s interview confirmed they contacted the facility regarding the pressure injury, but the facility stated they did not have knowledge. The facility provided basic services to R1 that included observations of R1. R1’s shower schedule for November 2020 reflected initials on the days R1 was provided showers. On 11/17/20, 11/20/20, 11/24/20, and 11/27/20 there were no initials to verify showers were provided or documentation to indicate R1 refused showers. The facility is required to meet the basic needs of the residents to include ensuring the residents are kept clean. Facility’s documentation of bathroom assistance reflected it was PRN, as needed. However, staff initials verified they assisted R1 with bathroom assistance for eight (8) of the thirty (30) days in November 2020, which indicated R1 required assistance. Staff interviews confirmed R1 was a full assist with toileting and diapers. Further staff interviews revealed finding R1 in soiled diapers on multiple occasions. Outside source interviews confirmed observing R1’s needs not being met due to being unkempt with dirty hair and black dirt on their feet. Based on interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation was found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Marie Hill whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1] 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 R1’s medical record reflected they were prescribed a specific pain medication on 10/16/20, a PRN, as needed. A review of R1’s Medication Administration Records (MARs) for October 2020 indicated the medication was dispensed on 10/17/20 for moderate pain. MARs for November 2020 indicated the specific PRN medication was dispensed on 11/02/20 for moderate pain and 11/06/20 for severe pain. The facility was dispensing the medication as needed. Outside source interviews revealed a medical professional contacted the facility to inquire about the pain medication being dispensed. The medical professional reported the facility stated R1 was not complaining of pain, and it was unknown if staff were asking R1 if they were in pain. According to medication documentation, the licensee followed the physician’s order and provided as PRN, as needed. Staff interviews confirmed medications were dispensed as prescribed. During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegations. The allegations are deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Marie Hill whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1]

LPA inquired about R2’s previous inappropriate sexual behaviors with Resident Service Director Priscilla Bermudes and it was revealed R2 is verbally inappropriate and will make sexually inappropriate statements to staff and residents. Bermudes stated R2 has never touched or harmed a resident. Therefore, based on interviews and record review, there was not enough information to corroborate the alleged allegation, the allegation “Resident was sexually assaulted while in care” has been deemed unsubstantiated at this time. 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. An exit interview was conducted where a copy of this report was discussed and provided to Executive Director Hill.

According to allegation, three weeks prior to November 24, 2020, R1 was dropped by an unnamed caregiver during a night shift. Interview with staff present on or around the timeframe mentioned stated they were unaware of R1 being dropped. Interview with outside source revealed that there were no instances of R1 being dropped. Interview with outside source also revealed that there was no injury on R1 to determine R1 was dropped. Records collected did not reveal any additional information to corroborate allegation. It was also alleged that facility staff did not report R1 being dropped to R1’s responsible party. Interviews with staff present on or around the timeframe mentioned stated they were unaware of R1 being dropped therefore it was not reported. Interview with outside source revealed there was no evidence to corroborate resident was dropped. Additionally, there were no records available to corroborate allegation. Based on Department’s interviews, and record reviews there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with Executive Director Marie Hill , to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.

Licensing Program Analyst (LPA) Jacqueline Shaw Ross arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by Executive Director, Marie Hill. LPA began inspection with introduction and visit purpose. The facility services clients ages 60 and over, and is approved for 96 non-ambulatory clients of which 10 may be bedridden, hospice care waiver for 35 clients. There is an Infection Control Plan on file. This a full memory care facility. Smoke alarms and fire extinguishers were tested and remain operable. Drills are conducted regularly. The last drill was conducted on 9/23/2023. Client Records-Incident Reports/Clients Rights-Information/Dental- LPA reviewed client records. Five (5) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. Personnel Records/Training/and Staffing- LPAs began review of employee records- Five (5) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrative organization. Food Service- Food prep areas are clean and organized. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a locked location for sharps in the kitchen. (Continued on LIC809C) 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 Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. LPA observed the facility to be clean and in good repair. The facility is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured 108.5 degrees F. Laundry is done in a large locked laundry room. There is a locked room for storing laundry soap and other chemicals. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. The LIC 610, emergency disaster plan is maintained posted on the wall. There are no firearms at this facility. There is not a fireplace at this facility. There is not a pool at the facility. During the tour of the facility, LPA observed flooring damage in the hallway of the West wing roughly two and a half feet by 4 feet long. Laminate flooring appeared to be removed, and freshly cemented. LPA was informed that a water leak was discovered Thursday afternoon, repairs began Friday. LPA observed the damaged flooring area was marked off with safety tape and safety cones. LPA was informed they are fully staffed have had no client accidents throughout the repair process. Administrator states they are waiting on the cement to dry and final repairs should be completed by early next week. LPA took a photograph of the damaged flooring. Medications - are centrally stored in two locked medication rooms located on the East and West side of the facility. There are locked cabinets allocated for medication storage. Centrally stored medication and destruction logs maintained separately. Based on the information received during this visit today, there are zero (0) deficiencies observed per Title 22, Division 6 of The California Code of Regulations. An exit interview was conducted and a copy of this report was provided to Administrator, Marie Hill.