Aegis Assisted Living of Fremont

On 02/03/2026 at 4:20 PM, Licensing Program Analyst (LPA) Patricia Manalo conducted a case management legal non-compliance visit and met with Health Services Director, Leslie Ibo. LPA explained to Ibo the purpose of the visit. This case management visit is conducted as follow up on the facility's compliance plan as a result of the Non-Compliance Conference (NCC) conducted on March 25, 2025. During the visit, LPA P. Manalo conducted an inspection of the Memory Care unit with Ibo. LPA reviewed R1 and R2's incidents dated on 01/07/2026 and 01/27/2026 that were reported to CCLD and residents' responsible party on a timely manner. Interview with Ibo revealed that when R1 had a witnessed fall and 911 was called when R1 verbalized that R1 was in pain. No deficiencies cited. Exit interview was conducted with Ibo and a copy of this report was provided.

On 02/03/2026 at 2:10 PM, Licensing Program Analyst (LPA) P.Manalo conducted an unannounced Case Management visit regarding a self-reported incident. Health Services Director, Leslie Ibo, self-reported the incident on 01/27/2026. Incident report and interview with Ibo revealed that on 01/26/2026, R1 left the community with friends and did not return. Ibo revealed that the police officers involved during the incident allowed R1 to leave the community since police officers were unable to restrain R1 from leaving. During the visit, LPA interviewed Health Services Director, R1's Durable Power of Attorney (DPOA), and attempted to interview police officer for more information. Interview with Ibo revealed that R1 has not returned to the facility and facility staff are providing R1's friends with R1's medication everyday. Additionally, Ibo stated that education has been provided to R1's friends each time medication is provided. LPA obtained the following documents including but not limited to staff roster, resident roster, facility's visitor log, R1's physician report, service plan, resident emergency information face sheet, police contact information, R1's POA documentation, Medication Release Records, and SOC341. LPA may return at a later time. No deficiencies cited. Exit interview conducted and a copy of this report provided.

On 07/01/2025 at 2:25 PM Licensing Program Analyst (LPA) P.Manalo conducted an unannounced Case Management visit regarding a self-reported missed medication that occurred on 06/12/2025. Health Services Director, Leslie Ibo self-reported the incident on 06/19/2025. LPA met with General Manager, Ryan Turner, and explained the purpose of the visit. LPA received an incident report that on 06/12/2025 for Resident 1 (R1) that revealed that R1 was not administered the insulin dose in the morning because the second safety on the needle remained intact causing the missed dosage of the medication. R1 was then given the lunch dosage after the incident. LPA reviewed Physician’s Fax Report dated 06/12/2025, Insulin Staff Training, Progress Notes, Aegis Medication Incident Report and June Emergency Paper Medication Administration Record (MAR). Progress Notes indicated that the facility contacted the appropriate parties such as R1’s physician and family. Progress Notes also stated that R1 was placed on monitoring and did not show any side effects from the missed medications. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted with General Manager Appeal Rights and a copy of this report provided.

On 08/18/2025 at 12:20 PM, Licensing Program Analysts (LPAs) P.Manalo and and K. Nguyen conducted an unannounced Case Management visit regarding a self-reported incident. Health Services Director self-reported the incident on 07/29/2025. LPAs met with Health Services Director, Brenda Silva and General Manager, Ryan Turner, and explained the purpose of the visit. LPA received a self-reported incident report from facility that indicated Resident 1 (R1) had an unwitnessed fall and incident report revealed that R1 sustained an avulsion fracture. LPAs reviewed the following documents such as R1's Physician's Report dated 05/13/2024, Physician's Fax, Report, After Visit Summary, Individualized Service Assessment, and email correspondence between facility and responsible parties. Interview with Health Services Director stated that the facility and R1's family are in communication regarding R1's care. No deficiencies cited during visit. Exit interview was conducted with Health Services Director, and a copy of this report was provided.

On 08/18/2025 at 11:40 AM, Licensing Program Analysts (LPAs) P.Manalo and and K. Nguyen conducted an unannounced Case Management visit regarding a self-reported incident. Health Services Director self-reported the incident on 07/17/2025. LPAs met with Health Services Director, Brenda Silva and General Manager, Ryan Turner, and explained the purpose of the visit. LPA received a self-reported incident report from facility that indicated Resident 1 (R1) had an unwitnessed fall and after visit summary stated that the resident had sustained a femur fracture. LPAs reviewed the following documents such as R1's Physician's Report, Individualized Service Assessment Plan dated 05/01/2025, 07/21/2025, 08/07/2025, and 08/18/2025, Facility Call Button Log, and After Visit Summary. Interview with Health Services Director stated that the resident was independent and Individualized Service Assessment dated 05/01/2025 stated that R1 will use their pendant to call on staff if assistance is needed. LPAs attempted to interview R1, however, R1 was unavailable during the the time. No deficiencies cited during visit. Exit interview was conducted with Health Services Director, and a copy of this report was provided.

On 02/03/2026 at 2:10 PM, Licensing Program Analyst (LPA) P.Manalo conducted an unannounced Case Management visit regarding a self-reported incident. Health Services Director, Leslie Ibo, self-reported the incident on 01/07/2026. LPA received a self-reported incident report from facility that indicated Resident 1 (R1) had and witnessed fall while R1's private caregiver was escorting R1 to the bathroom in R1's room on 01/03/2026. Incident report revealed that R1 attempted to push the private caregiver away which resulted in R1's fall. R1 was sent to the Emergency Room and was diagnosed with a hip fracture. R1 is currently at a skilled nursing facility (SNF). LPA reviewed the following documents including but not limited to R1's Physician's Report, communication log with family and doctor's, service plan, call pendant alert log, private caregiver contact information, Home Health Visit Communication form, staff roster/ schedule, staff contact information, and resident roster. Interview with Ibo indicated that a new physician report will be obtained and sent to CCLD when R1 is discharged from the SNF. Additionally, Ibo followed up with the SNF that revealed that there is no discharge date and R1 is undergoing physical therapy. LPA may return at a later time. No deficiencies cited during visit. Exit interview was conducted with Health Services Director, and a copy of this report was provided.

On 08/18/2025 at 2:00 PM, Licensing Program Analysts (LPAs) P.Manalo and K.Nguyen arrived unannounced to conduct a case management visit. LPA met with General Manager, Ryan Turner, and explained the purpose of the visit. While LPAs was at the facility for another visit, LPAs observed the following deficiency: LPAs observed Tide Pod in the washing machine room in Memory Care 2. LPAs observed Sanitation Wipes unlocked in Memory Care 1. The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.

On 08/18/2025 at 9:40 AM, Licensing Program Analysts (LPAs) Patricia Manalo and Kelly Nguyen conducted a case management-legal non-compliance visit and met with General Manager, Ryan Turner and Health Services Director, Brenda Silva. LPAs explained to Turner and Silva the purpose of the visit. This case management visit is conducted as follow up on the facility's compliance plan as a result of the Non-Compliance Conference (NCC) conducted on March 25, 2025. During the visit, LPA P. Manalo conducted an inspection of the Memory Care unit and reviewed Resident 1 (R1) and Resident 2 (R2) files. Health Services Director and LPAs had a discussion regarding the facility's fall prevention plan. No deficiencies cited. Exit interview was conducted with General Manager and a copy of this report was provided.

On 07/30/2025 at 12:00PM Licensing Program Analyst (LPA) P.Manalo conducted an unannounced Case Management visit regarding a self-reported incident. Health Services Director self-reported the incident on 07/07/2025. LPA met with Care Director, Maryrose Vinarao, and explained the purpose of the visit. LPA received a self-reported incident report from facility that indicated Resident 1 (R1) had an unwitnessed fall and after visit summary indicated that the resident had a wrist fracture. During the visit, LPA reviewed R1's Individualized Service Plan, Medication List, Transfer/Discharge Report and Order Summary Report from previous skilled nursing facility, and After Visit Summary dated 07/06/2025. A review of resident's Individualized Service Plan dated 06/22/2025 and Order Summary Report from previous skilled nursing facility revealed that the resident has a diagnosis of bone density and structure. No deficiencies cited during visit. Exit interview was conducted with Care Director and a copy of this report was provided.

On 07/30/2025 at 10:25 PM Licensing Program Analyst (LPA) P.Manalo conducted an unannounced Case Management visit regarding a self-reported medication error that occurred on 07/20/2025. Health Services Director, Brenda Silva self-reported the incident on 07/24/2025. LPA met with Care Director, Maryrose Vinarao, and explained the purpose of the visit. General Manager was unavailable during today's visit. LPA received an incident report that on 07/24/2025 Resident 1 (R1) was given a PRN medication after the medication has been discontinued. During the visit, LPA reviewed R1's After Visit Summary, Medication List, Medication Administration Training, Physician's Fax Report, Individual Narcotic Record, and Email Correspondence with R1's family. Progress Notes indicated that the facility contacted the appropriate parties such as R1’s physician and family. Progress Notes also stated that R1 was placed on monitoring and did not show any side effects from the medication error. Interview with Care Director revealed that Staff 1 (S1) gave R1 the PRN medication before checking the Medication Administration Record (MAR). The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiency by POC date may result in additional Civil Penalty. Exit interview conducted with Care Director. Appeal Rights and a copy of this report provided.

On 07/10/2025 at 1:05 PM Licensing Program Analyst (LPA) P.Manalo conducted an unannounced Case Management visit regarding a self-reported incident. Health Services Director self-reported the incident on 07/03/2025. LPA met with Health Services Director, Brenda Silva, and explained the purpose of the visit. General Manager, Ryan Turner, gave authorization for Silva to sign the report. LPA received a self-reported incident report from facility that indicated Resident 1 (R1) had an unwitnessed fall and after visit summary stated that the resident was treated for a closed hip fracture. During the visit, LPA reviewed R1's Physician's Report dated 01/30/2023 and 07/09/2025, Individualized Service Plan, Individualized Service Assessment, and After Visit Summary dated 07/10/2025. A review of R1's Physician Report revealed that R1 has a diagnosis of osteopenia. R1's Individualized Service Plan dated 06/21/2025 showed that R1 is independent with most Activities of Daily Living's (ADLS). LPA spoke with R1 during the visit. R1 stated that R1 lost their balance and fell on the ground. R1 stated that R1 fell on R1's hips. R1 stated that staff arrived shortly after to assist R1. No deficiencies issued during the visit and a copy of this report provided.

On 05/06/2025 at 2:15 PM, Licensing Program Analysts (LPAs) P.Manalo and L. Fontanilla conducted an unannounced Case Management visit regarding a self-reported incident. Health Services Director self-reported the incident on 04/29/2025. LPAs met with Health Services Director, Leslie Ibo, and explained the purpose of the visit. Health Services Director self-reported multiple fall incidents that occured with Resident 1 (R1) on 04/25, 04/26, 04/27. LPAs interviews with Health Services Director indicated that R1 has a 1:1 caregiver from 10 PM to 6 AM daily. Record reviews shows that the facility updated R1's Service Plan and Individualized Service Assessment after the incident of the multiple falls. R1 has also moved to the Memory Care Unit and hasn't fallen since the implementation of the their new plan. No deficiencies cited during visit. Exit interview was conducted with Health Services Director, and a copy of this report was provided.

On 07/01/2025 at 12:40 PM Licensing Program Analyst (LPA) P. Manalo conducted an unannounced Case Management visit regarding a self-reported restraint abuse that occurred on 06/23/2025. Health Services Director, Leslie Ibo self-reported the incident on 06/23/2025. LPA met with General Manager, Ryan Turner, and explained the purpose of the visit. LPA reviewed the following documents such facility’s Resident Incident Report, Physician’s Fax Report, Progress Notes, and SOC341. LPA also reviewed the AUGi monitoring system during today's visit. LPA interviewed Staff 1 (S1) and Staff (2). Interview with S1 revealed that S1 heard motion in R1’s room and checked the AUGi Monitoring System. AUGi system showed that R1 was laying down and the 1:1 caregiver was holding R1 down on the bed. S1 and another staff member proceeded to intervene. Interview with S2 and Progress Notes for R1 showed that the R1 did not sustain injuries during the assessment. General Manager stated that the private caregiver was sent home and will not be allowed at the facility anymore. LPA will have the facility send the 1:1 Private Caregiver Contract by 04/07/2025. No deficiencies cited during visit. Exit interview was conducted with General Manager and a copy of this report was provided.

On 05/06/2025 at 1:10 PM, Licensing Program Analysts (LPAs) Patricia Manalo and Luisa Fontanilla conducted a case management-legal non-compliance visit and met with General Manager, Ryan Turner and Health Services Director, Leslie Ibo. LPAs explained to Turner and Ibo the purpose of the visit. This case management visit is conducted as follow up on the facility's compliance plan as a result of the Non-Compliance Conference (NCC) conducted on March 25, 2025. During the visit, LPA P. Manalo conducted an inspection of the Memory Care unit with Turner and observed laundry baskets blocking two resident's door. The facility removed the baskets during the visit. A technical violation was issued during the visit. Exit interview was conducted with General Manager and a copy of this report was provided.

On 04/07/2025 at 2:04 PM Licensing Program Analysts (LPAs) P.Manalo and K. Nguyen conducted an unannounced Case Management visit regarding a self-reported incident. Health Services Director self-reported the incident on 03/15/2025. LPAs met with Health Services Director, Leslie Ibo, and explained the purpose of the visit. LPA received a self-reported incident report from facility that indicated that the Resident 1 (R1) had an unwitnessed fall and after visit report indicated that the resident sustained closed compression fracture. LPAs reviewed the After Visit Summary dated 03/14/2025. The After Visit Summary indicated that there is no evidence of spine fracture and is due to age indeterminate. No deficiencies cited during visit. Exit interview was conducted with Health Services Director, and a copy of this report was provided.

On 04/07/2025 at 1:25 PM Licensing Program Analysts (LPAs) P.Manalo and and K. Nguyen conducted an unannounced Case Management visit regarding a self-reported incident. Health Services Director self-reported the incident on 03/15/2025. LPAs met with Health Services Director, Leslie Ibo, and explained the purpose of the visit. LPA received a self-reported incident report from facility that indicated Resident 1 (R1) had an unwitnessed fall and after visit summary stated that the resident had a closed T11 fracture. LPAs obtained the following documents such as R1's Physician's Report from move in date, Emergency ID Face Sheet, and After Visit Summary from 03/15/2025. LPAs record review indicated that R1's Physicians Report and Emergency ID Face Sheet indicated that R1 had sustained a unspecified fracture prior to moving in. No deficiencies cited during visit. Exit interview was conducted with Health Services Director, and a copy of this report was provided.

This LIC809 is an amendment to the original LIC809 dated 12/30/2021. On 12/30/2021, Licensing Program Analyst (LPA), L. Hall generated case management visit under this facility. LPA did correct and generate case management visit under the correct facility profile Aegis Gardens #019201063 the same day. On 12/30/2021 at 1:40PM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a case management visit regarding an incident report received on 12/28/2021. LPA met with Health and Services Director, Cathy Zhou and Emily Poon, General Manager. Incident report dated 12/28/2021 revealed that Resident 1 (R1) reported abuse from Staff 5 (S5). Facility notified law enforcement and R1's responsible party. LPA interviewed three (3) of four (4) staff. LPA was not able to interview Resident 1 (R1) due to diagnosis. Interview with Staff 1 (S1) revealed that S5 was the caregiver for R1 on the day of the incident. R1 was being assisted by S5 in the bathroom when the incident occurred. R1 reported the incident to Staff (S4). S4 reported the incident to S1. S5 was suspended immediately and after the investigation was terminated on 12/28/2021. Facility will be conducting an abuse training for all staff on 1/5/2022. LPA collected the following documents: Staff roster, Resident roster, and training documents for S5. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

On 02/20/25 at 2:43PM, Licensing Program Analyst (LPA) Daisy Panlilio arrived unannounced to conduct a case management visit in response to a priority 1 complaint received on 04/09/24. LPA met with Executive Director (ED) and explained the purpose of the visit. Reporting party (RP) stated that review of video footage on 03/03/24 showed a male memory care resident (R5) entered resident's (R1) bedroom at 0449 hours and stayed there until 0600 hours. RP stated that R1's bedroom had a motion sensor that would alert staff of any movements inside. RP stated that no staff came to remove R5 from R1's room. R5 left the room on his own at 0600 hours. RP also stated she observed memory care residents left unsupervised in the common room of the memory care unit while she was visiting R1 on May 2024. LPA interviewed ED who stated that he discussed the incidents with RP and conducted in-service staff retraining regarding proper care and supervision of residents with dementia on 04/12/24. No deficiency cited during visit. Exit interview conducted and a copy of this report provided.

On 1/15/2025 at 11:15 AM Licensing Program Analysts (LPAs) P.Manalo and L. Fontanilla conducted an unannounced Case Management visit regarding a self-reported incident. Health Services Director self-reported the incident on 01/13/2025. LPAs met with Health Services Director, Leslie Ibo, and explained the purpose of the visit. LPAs obtained the following documents such as R1's Physician's Report, Emergency ID Face Sheet, Physician's Fax Report Notification, Discharge Summary from 12/20/2024, Internal Progress Notes, Care Plan, Individualized Service Assessment, Medication Administration Record (MAR), Appraisal Needs and Services Plan, and Staff Schedule. LPAs requested a copy of the Death Certificate to be sent to CCLD on 02/15/2025. No deficiencies cited during visit. Exit interview was conducted with Health Services Director, and a copy of this report was provided.

Licensing Program Analyst (LPAs) Manalo and Clancy-Czuleger arrived unannounced to conduct a case management visit in response to the Unusual Incident Report (UIR) submitted by the facility. LPA's met with Leslie Ibo, Health and Wellness Director and Ryan Turner Executive Director and explained the purpose of the visit. Resident (R1) had passed away on 10/17/2024. On October 20, 2024, Health and Wellness Director (S1) started the process of medication destruction, when it was observed that an unused bottle of narcotics medications was missing. Medtech’s and nurses started to look for the medication. All medication carts and overflow cabinets were searched and still could not find the medications. An internal investigation was conducted, medtech’s and nurses was interviewed. The incident was reported to Fremont Police with the incident event number is P24125430. In-service with wellness team started on 10/22/2024 with the following topics: narcotic count, documentation, medication error, medication destructions and other topics. Regional Health Services Director and General Manager was notified regarding the incident. Our community started to have two staff signing off for the narcotics, nurses will audit narcotics weekly. No deficiency cited. Exit interview conducted and copy of this report provided .

On 12/06/2024 at 8:55 AM Licensing Program Analysts (LPAs) P.Manalo and L. Fontanilla conducted an unannounced Case Management visit regarding a self-reported abuse that occured on 11/29/2024. Health Services Director self-reported the incident on 12/05/2024. LPAs met with Executive Director, Ryan Turner, and explained the purpose of the visit. LPAs interviewed R1, R2, Executive Director, and Health Services Director regarding the incident. R1 has dementia diagnosis and lives in the Memory Care Unit. R2 stated that S1 pulled R1's leg while R1 was in bed. LPAs interviewed Executive Director and Health Services Director who stated that S1 was terminated on 12/05/2024 and has been removed from the facility roster. LPAs obtained the following documents such as R1's Physician's Report, S1's Termination Paper, S1's Employee Files, Staff Roster, and Resident Report. No deficiencies cited during visit. Exit interview was conducted with Executive Director and a copy of this report was provided.

Licensing Program Analyst (LPAs) Manalo and Clancy-Czuleger arrived unannounced to conduct a case management visit in response to the Unusual Incident Report (UIR) submitted by the facility. LPA's met with Leslie Ibo, Health and Wellness Director and Ryan Turner Executive Director and explained the purpose of the visit. Resident (R1) had a sudden death and was not on hospice. Health and Wellness Director (S1) stated that R1 was receiving morning adl’s with care staff when she started throwing up & loss consciousness. CPR was administered for about 45 minutes and tried to resuscitate. R1 had a history of colon cancer and colon diverticulitis, and had a diagnosis of dementia and hypertension. Police were called (badge #16133) and stated that the coroner does not need to visit the community. No deficiencies cited during today's visit. Exit interview conducted and a copy of this report provided.

On 10/28/2024 at 9:00AM, Licensing Program Analysts (LPAs) P. Manalo and J. Clancy-Czuleger arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Health Services Director, Leslie Ibo and explained the purpose of the visit. Administrator, Ryan Turner, arrived shortly after. LPAs toured the facility with Administrator, Ryan Turner, including but not limited to residents' apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPAs observe lighting in all rooms are adequate for the comfort and safety of the residents. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in a sample of residents’ shared bathroom were measured at 115 and 114.1 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars with non-skid shower pan. 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. At 9:45 AM, LPAs reviewed 8 residents records. At 10:45 AM, LPAs reviewed 8 staff records and 8 of 8 are associated to the facility. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was observed last serviced on 08/28/2024 and kitchen fire extinguisher was last serviced on 08/28/2024. First aid kit was observed to be complete. Continue 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 Continue from LIC809... Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 11/04/2024: LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Liability Insurance No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

ALLEGATION: Neglect/Lack of Supervision – Staff did not provide adequate supervision resulting in resident (R1) sustaining multiple fractures while in care. INVESTIGATION FINDING: Substantiated During investigation, the department conducted interviews of facility staff (Care Director (CD), Regional Health Services Director (RHD), S1, S2) & R1’s responsible party (POA) and reviewed resident (R1) documents. Review of R1’s incident reports showed R1 had sustained 5 documented falls at the facility since she was admitted in 2022. Staff (CD, RHD) both denied receiving reports from care staff that R1 needs a 1:1 caregiver citing R1 higher level of care. Despite having multiple fall prevention methods in place and staff expressing their concerns to management in not being able to provide adequate care, R1 continued to have un-witnessed and witnessed falls in the facility, twice sustaining serious fractures in her femur and pelvis, Based on observations and interviews which were conducted and record review(s), the department has substantiated the allegation that staff did not provide adequate supervision resulting in resident (R1) sustaining multiple fractures while in care. The preponderance of evidence standard has been met. Therefore, the above allegation was found to be substantiated. Immediate civil penalty of $500 assessed during visit for staff failing to provide adequate care and supervision to resident resulting in resident sustaining multiple fractures while in care. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.

S1 stated that while conducting the investigation into the situation S3 admitted to placing the laundry baskets in front of the residents’ rooms to prevent them from wandering while she did her work. LPA reviewed S3’s personnel file and found the S3 was separated from the facility on 4/22/24 for “misconduct: locked the resident in the apt with cart outside the door.” LPA also reviewed the photos that S2 took of the laundry baskets blocking the residents' rooms. Based on LPA document review and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted, a copy of this report and appeal rights provided.

...Continued from LIC9099-A 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. 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 ....Continued from 9099 Based on LPA’s interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . California Code of Regulations, Title 22 has been cited. Exit interview conducted. A copy appeal rights, and this report provided.

On 9/25/24 at 12:30 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to deliver amended LIC9099D page from visit conducted on 9/24/24 . LPA met with Ryan Turner, General Manager and explained the purpose of the visit. LPA delivered amended LIC9099D. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

...Continued from LIC 9099 The first unwitnessed fall was discovered by S2; documents support that care staff (caregivers) helped R1 up and provided first aid to her finger. The second unwitnessed fall, S1 delayed reported that around 1120 hours, she observed R1 on the floor in front of a chair she was previously sitting on at around 1100 hours. Staff assisted R1 to her feet and, as per interviews, guided her back to the dining area before later presenting her to her family for a visit. Care staff did not notify the nurse on duty for additional assessment for both unwitnessed falls. On the allegation: Staff did not report incident to CCL. Based on interviews and records review the facility did not report to the department that R1 had 2 unwitnessed falls on June 16, 2022. In an interview with S1 said that for both falls reported by S2, facility was not able to find the incident reports or the COC report to provide to CCLD. On the allegation: Staff did not communicate with the responsible party of incident. Based on interviews and records review the facility did not report to R1’s family the residents change of condition or falls that occurred. In an interview with the investigator S1 confirmed that no one updated R1’s family about the investigation. Based on the investigation, above allegations are deemed Substantiated. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC 9099D. Exit interview conducted. Appeal Rights and a copy of this report provided.

Continue from Lic9099 It was alleged that staff abused resident while in care and staff violated residents personnel rights. Based on interviews conducted. All staff have stated that they have not witnessed any residents’ being abused nor their personnel rights being violated. All staff gave residents’ their personal phone and call button to call as they please. Residents’ stated during interview that they are treated well, and staff has not abused them nor violated their personnel rights. Residents’ also stated that staff allows them to use their personal phones, and use the call button for assistance if they need any type of help. LPA review R1’s medical record which indicated R1 sustaining a fall resulting in a hip fracture in November 2021. Based on Interviews and record review conducted, Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore, the allegations are UNSUBSTANTIATED . Exit interview conducted with GM and HSD, and a copy of this report provided.

On 04/11/24 at 12:40PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced Health and Safety check due to the department receiving a priority 1 complaint. During the health and safety check, LPA observed a total of 27 staff members and 72 residents at the facility. LPA toured facility with general manager/administrator, including but not limited to bedrooms, kitchen, dining rooms, activities rooms, bathroom, outdoor garden and common areas. LPA observed residents comfortable in their surroundings, eating their lunch meals and relaxing in common areas with family and friends. 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.

On 9/1/2023 starting at 11:48 AM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct 1-Year Annual Required Inspection. LPA met with MaryRose Vinarao, Care Director (CD) and explained the purpose of the visit. The facility’s fire clearance was approved for one-hundred-ten (110) ambulatory residents, which seventy (70) may be non- ambulatory, thirty (30) may be bedridden, and approved for thirty-two (32) hospice residents. Upon entry, LPA observed four (4) staff and eight (8) residents present during inspection. Starting at 12:13 PM, LPA toured facility with CD, including but not limited to eighty (80) bedrooms, eighty (80) bathrooms, kitchen, court yard. The facility consists of 80 total bedrooms which 8 are shared, and seventy-two (72) are private. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 74 Degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents'. The hot water temperature in residents’ common area bathroom was measured at 116.0 Degrees Fahrenheit. Residents’ bathrooms are equipped non-skid mats. There is a minimum of one-week supply of nonperishable and 2-day supply of perishable foods. Sharps and toxins were locked and inaccessible to residents'. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was observed last serviced on 7/25/2023. First aid kit was observed to be complete. Continue on Lic809-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 Continued from Lic809 Starting At 1:27 PM, LPA reviewed 10 of 10 staff records. At 2:09 PM, LPA reviewed 10 of 10 residents' records. At 3:39 PM, LPA reviewed a sample of 10 of 10 residents' medications. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 9/8/2023: · LIC 308 Designation of Administrative Responsibility · LIC 500 Personnel Report · LIC 610E Emergency Disaster Plan (9 Pages) · Liability Insurance No deficiencies cited during visit. Exit interview conducted with CD, and a copy of this report provided.

Continued from Lic9099 Based on Interviews and record review conducted, Although the allegation may have happened or are 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 with ADM, and a copy of this report provided.

Continued from Lic9099. It was alleged that: Licensee did not follow proper eviction procedures for resident. Based on interviews and record review conducted, LPA confirmed with S1 and S2 that R1 was unsafe for the community and R1 needed a higher level of care. S1 and S2 notified Rp about R1’s aggressive behavior and that R1 is a harm to herself, staff and other residents in the community. It was stated by S1 and S2 that R1 did not receive an eviction notice, and that S1 and S2 verbally informed Rp that the community can not meet R1's care needs. Based on LPAs interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC 9099D. Exit interview conducted with ADM, and a copy of this report provided along with appeal rights. 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 Continued from Lic9099. It was alleged that: Facility staff did not properly supervise resident resulting in elopement. Based on interviews conducted, S1, S3, and S4 were supervising R1 while R1 left the facility. Staff did not want to force R1 to come back into the facility and staff walked with R1 to food max store while 911 was called. Rp was informed that R1 left the facility. Rp arrived too food max store and drove S1 and R1 back to the community. No police report was generated. Based on Interviews conducted, Although the allegation may have happened or are 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 with ADM, and a copy of this report provided.

On 8/24/2023 starting at 1:42 PM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct a case management visit to deliver amended report originally dated 7/19/2023. LPA met with Shashi Madahar, Administrator and informed her the reason for visit. During visit, LPA obtained original report dated 7/19/2023 from Administrator. No deficiencies are being cited on this date. Exit interview conducted, and a copy of this report provided.

On 6/16/23 at 1:55 PM, Licensing Program Analyst (LPA) Greg Clark conducted a Health & Safety inspection as a result of a priority 1 complaint. LPA met with Shashi Madahar, Health Service Director (HSD) and explained the purpose of the visit. LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, and outdoor area. Hot water temperature was measured at 113.3 degrees F in a vacant bedroom. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Refrigerator temperature was observed at 39 degrees F and freezer was at 0 degrees F. Resident's medications were kept locked in several med carts. Smoke detectors are interconnected with the sprinkler system. Carbon monoxide detector was observed and operational. First-aid kit was complete. Fire extinguisher was observed to be full and last serviced on 8/01/22. There are no accessible bodies of water observed. Indoor and outdoor passageways are free of obstruction. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

Continued from Lic9099 It was alleged that, staff do not report resident's change in condition to responsible party. Based on record review and interviews conducted, R1’s family was notified on 6/27/2021 when R1’s foot infection began. Wellness nurse documented foot infection on care notes and the process of the infection. Wound care began on 6/27/2021 and has been implemented by wellness nurse and continues to receive wound treatment by nurse in the community. Needs/service plan dated for 10/26/2022 states R1 is at increased risk for skin breakdown and for staff to conduct routine checks for new skin issues and to report to nurse. R1’s foot infection is on-going and is being cared for and documented by community wellness nurse. It was alleged that, staff do not follow resident's physician's order. Based on record review and interviews conducted, progress notes stated on 6/27/2021, R1’s foot infection began, and physicians’ orders was received for R1’s foot infection for wound treatment. Wound care was being carried out by wellness nurse starting on 6/27/2021 and continued to follow Physicians order. On 7/30/2021, a new physicians order was placed for R1’s foot swelling due to leg infection. On 9/12/2022, a new order was received for leg infection and were followed; Orders by the physicians were carried out until further notice and has been documented in progress notes. It was alleged that staff, do not assist resident with grooming. Based on record review and interviews conducted, wellness nurse have performed ADLs to include grooming for R1 on a daily basis dated June 2022- October 2022. LPA received R1’s ADLs service delivery records that indicates ADLs were performed by staff. R1’s ISP has also indicated that ADLs including grooming are to be performed twice a day by staff. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation are UNSUBSTANTIATED . Exit interview conducted with ADM, and a copy of this report provided.

On 12/30/2022, while at the facility for another reason, Licensing program analysts (LPAs) L. Fici And J. Clancy-Czuleger conducted a case management about an incident that the LPA was informed about. LPA confirmed the incident occurred and the administrator attempted to fax it to CCL. LPA discussed with administrator the reporting requirements. No deficiency cited during visit. Exit interview conducted with administrator, and a copy of this report provided.

It was alleged that staff handled resident in a rough manner, causing injury. Based on interviews with 4 of 4 staff members, staff demonstrated how to pick up a resident that needs assistance after a resident has a fall. R1 had a fall on 12/19/2019, and an incident report was received on 12/19/2019. R1 sustained a knee injury due to R1 falling. Staff also informed LPA what the facility procedures were when handling a resident in care that has a fall. Staff tried to check temperature and blood pressure (BP), but R1 refused. R1 stated to S1 that R1’s lost her footing and fell down; Tylenol was given to R1. Photos were emailed to LPA with no date stamp of when pictures were taken. Facility staff contacted R1’s responsible party and community directors regarding the incident and an Lic624 was submitted to CCL. It was alleged that staff did not respond to resident’s request for assistance in a timely manner. Based on interviews, and record review conducted, resident received assistance in a timely manner by pressing the PHB (Call button) which alerted staff members that the resident needed assistance. A PHB call button log was received and reviewed; resident was assisted within 10 minutes by care staff. It was alleged that staff did not seek medical attention for resident in a timely manner. Based on record review and interviews conducted, staff did seek medical attention for resident in a timely manner. Staff called royal ambulance for R1 to be taken to the hospital after R1 was experiencing left arm pain on 12/24/2019 due to the fall resident sustained on 12/19/2019. Staff informed R1’s daughter that royal ambulance was called. Staff was advised to also call 911 for resident. LPA received and reviewed discharge papers dated for 12/24/2019, and did not identify any broken bones, breaks, or fractures during visit. Continued on Lic9099-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 It was alleged that facility retained resident needing a higher level of care. Based on record review and interviews conducted, resident is currently receiving care by wellness nurse due to foot infection that began on 6/27/2021. Wellness nurses continues to monitor foot infection to ensure no further infection occurs. LPA obtained care notes which indicate that care is being given to resident regarding foot infection. Wellness nurse is documenting the care that is being implemented while R2 currently resides in the community; care notes have indicated that care continues to be provided by wellness nurse. Primary care physician (PCP) is in communication with wellness nurse. It was alleged that staff did not report an incident involving resident to their representative. Based on record review and interviews conducted, R2’s representative was notified about the incident that occurred on 6/15/2021 when R2 had a fall hurting his left elbow. Resident received first aid from facility and 911 was called for R2. R2 was transferred to Fremont hospital; responsible parties were updated accordingly. Both incidents, 12/19/2019 and 6/15/2021 were documented and reported on an Lic624. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED . Exit interview conducted with ADM and Health and Service Director, with a copy of this report provided.

On today's date, 10/6/2022, at 12:55 PM, Licensing Program Analyst (LPAs) L. Fici and C. Lin arrived unannounced to conduct Infection Control Inspection. LPAs met with Shashi K Madahar , Health Services Director (HSD) and explained the purpose of the visit. During the inspection, LPAs toured facility including but not limited to common areas, hand washing stations, bedrooms, bathrooms, kitchen and courtyard. LPAs observed COVID-19 signage throughout the facility. Hand washing signs were posted at hand washing stations. LPAs observed PPE's are plentiful. Food and paper supplies are sufficient. Hand sanitizer is provided at facility entrance. LPAs observed water temperature in the memory care unit bathroom measured at 113.2 degrees F. Fire extinguisher was last serviced on 8/12/2022. LPAs observed facility passages inside and out are free of obstruction. First aid kit was observed to be complete. Smoke and carbon monoxide detectors were observed and maintained. Common areas are disinfected 3 or more times a day. During record review, LPAs observed facility has a copy of Infection Control Plan and emergency disaster plan on file. No deficiencies cited during visit. Exit interview conducted with Health Services Director and a copy of this report provided.