Ivy Park at Hayward

Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct another case management as follow-up to the case management conducted on December 15, 2020. LPA requested for copies of LIC601 Identification and Emergency Notification, Physician's Report, Pre-placement Appraisal, Appraisal/.Needs and Services Plan, staff schedule. On December 12, 2020, R1 was found not in his room when staff brought him lunch. Staff searched the dining room and common areas but unable to find him. Staff reported to Wellness Director (WD). Further search done but unsuccessful. Responsible person, executive director and associate director were informed. WD was about to call the police when R1 returned with police escort. Review of resident’s (R1) LIC602A Physician’s Report revealed R1 is confused/disoriented, has wandering and sundowning behaviors and can not leave the facility unassisted. Deficiency is cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of correction (POC) by plan of correction due date and any repeat violations within 12 month period may result in civil penalties. Deficiency and plan and proof of correction were discussed with Apolinario 'Paul' Gozon. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.

While the Department conducted investigation of complaint (Control # 15-AS-20230801150316) and upon review of records and interviews, it was learned that fift assist had to be called each time in order to get R1 up. Facility staff admitted that R1 would fall “every single day”. All facility staff interviewed stated they did not believe they could provide the level of care R1 required but kept R1 at the facility anyway. LPA discussed the above with Executive Director (ED) Nansiela 'Nancy' Randhawa. Deficiency is from Title 22 California Code Regulations and listed on 809D. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12-month period may result in civil penalty. Deficiency and plan and proof of correction were discussed with the ED. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.

While at the facility for other reason, Licensing Program Analyst (LPA) Delmundo discussed with Executive Director Apolinario 'Paul' Gozon the following: 1. Conditional use permit for the application for increase in capacity from 99 to 170 (assisted = 130; memory care = 40). Paul Gozon indicated he will follow-up with Associate Planner Development Services before the end of this week and will update LPA. 2. Construction/upgrade - LPA conducted a quick tour of the first and second floors with Paul Gozon. When verified, he stated there are no alterations on the physical plant and all work which LPA observed on-ongoing are all upgrades. 3. Delayed egress - to be installed on the second floor. 4. Application for increase capacity process 5. Fire Safety Inspection Request LPA to review the second floor sketch submitted by Paul Gozon on August 10, 2021. Once review is completed, LPA to submit the sketches and STD850 Request for Fire Safety Inspection to the fire department. Exit interview conducted and copy of this report provided.

Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management in response to Unusual Incident Reports (UIRs). SOC341 and Death Report submitted by the facility. LPA met with Associate Executive Director (AED) Rosana Frias and informed the reason for visit. UIRs indicated the following: 1. Resident (R1) UIR indicated that on 11/12/25, the facility received a call from a community that R1 was at the community's lobby. The Resident Care Coordinator and Memory Care Director went to the community and brought R1 back to facility. Family member was informed. 2. Death Report (DR) for resident (R2) DR indicated R2 passed on 11/09/25. R2 was in hospital ICU at the time of death. R2 was sent out to the emergency on 9/29/25 when R2 cried of head pain after an unwitnessed fall. 3. Resident (R3) On 11/24/24, R3 reported missing $800 in cash in her apartment. Executive Director met with R3, checked R3's apartment and didn't find any cash in the apartments and bags R3 said R3 keeps. There was no witness to the said incident. The facility also submitted a copy of SOC341. continued on 809C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 On this same day, 12/02/25, LPA reviewed residents' files and obtained copies of including but not limited to the following documents: LIC601 Identification and Emergency Contact Information; LIC602A Physician's Reports; Care Plan; LIC621 Client/Resident Personal Property Valuables. LPA checked the front door and conducted interviews. LPA observed the following: -at 12:00 pm, R1's LIC602A Physician's Report showed R1 has major neurocognitive disorder and cannot leave the facility unassisted. R1's assessment dated 11/17/25 not consistent with current care need. Assessment indicated resident wanders only within the common areas of the secured community . -at 12:20 pm, the front entrance/exit door does not have auditory signal. Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates and any repeat violation within 12 month period may result in civil penalty. Deficiencies and plan and proof of corrections were discussed with AED. Exit interview conducted. Appeal Rights,LIC9098 Proof of Correction form and copy of this report provided.

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office , 1515 CLAY STREET, STE. 310 OAKLAND , CA 94612 This is an official report of an unannounced visit/investigation of a complaint received in our office on 08/01/2023 and conducted by Evaluator Alicia Delmundo -Resident (R1) sustained a fracture while in care. -Resident (R1) had multiple falls during transfers. -Staff is not providing appropriate assistance during transfers. On this day, June 4, 2025, at 2:15 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings for the above allegations. LPA met with Executive Director (ED) Nansiela 'Nancy' Randhawa, and informed the reason for visit. During the course of investigation, the Department obtained copies of including but not limited to the following resident’s documents: LIC601 Identification and Emergency Contact Information; Appraisal/Assessment; LIC602A Physician's Report; Unusual Incident Reports (UIRs); facility notes; doctor's notes; medical records. Copies of resident roster and staff schedules were also obtained. The following were interviewed: resident’s (R1) family member (FM1) on 8/15/23; staff (S1, S2, S3, S4) and Associate Executive Director (AED) on 8/21/23; residents (R1, R2, R3, R4) on 8/21/23; resident (R5) on 9/06/23 ....continued on 9099C (page 2) SUPERVISORS NAME : Bennett Fong LICENSING EVALUATOR NAME : Alicia Delmundo LICENSING EVALUATOR SIGNATURE : DATE: 06/04/2025 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office , 1515 CLAY STREET, STE. 310 OAKLAND , CA 94612 Page 2 Allegation: Resident sustained a fracture while in care. LIC602A Physician’s Report showed R1 as non-ambulatory, cannot bathe self and not able to care for own toileting needs. FM1 stated she took R1 to the hospital in April 2023 where R1 was assessed and determined R1 needs a wheelchair. R1 was then upgraded to a tier two, which means R1 needs two people assistance during transfers. FM1 further indicated she has witnessed R1 being transferred by only one person “multiple times”. Incident reports dated 2/27/23, 4/07/23, 6/29/23, 7/14/23, 7/15/23, and 7/26/23 noted R1 sustaining the same type of fall while the facility staff walked R1 to the bathroom. Incident report dated 7/26/23 noted that R1 was helped up from bed and was about to walk with walker to the bathroom when R1’s legs gave out and R1 indicated her legs getting weak and were hurting. R1 fell on her knees and facility staff helped R1 sit up. Lift assist was called to help get R1 up, but R1 could not get up after several attempts with the medics. R1 was taken to the hospital. Medical Records reflected that R1 sustained a displaced supracondylar fracture without intercondylar extension of the lower end of her left femur. Based on records review and interviews, the allegation is substantiated. Allegation: Resident had multiple falls during transfers. FM1 stated she took R1 to the hospital in April 2023 where R1 was assessed and determined R1 needs a wheelchair. R1 was then upgraded to a tier two, which means R1 needs two people assistance during transfers.FM1 further indicated she has witnessed R1 being transferred by only one person “multiple times”. Incident reports dated 02/27/2023, 4/07/23, 6/29/23, 7/14/23, 7/15/23, and 7/26/23 note R1 sustaining the same type of fall while the facility staff walked R1 to the bathroom. Lift assist had to be called each time in order to get R1 up. Facility staff admitted that R1 would fall “every single day”. All facility staff interviewed stated they did not believe they could provide the level of care R1 required but kept R1 at the facility anyway. In April of 2023, R1 returned from the hospital to the facility confined to a wheelchair, however, the wheelchair did not fit through R1’s bedroom or bathroom door. Two facility staff would have to physically lift R1 out of R1’s wheelchair and into a standing position supported by R1’s walker. Facility staff would then walk behind R1 as she walked into her bedroom and bathroom. R1’s physical condition prevented her from walking at all which caused R1 to fall constantly. Therefore, the allegation is substantiated. ......continued on 9099C (page 3) SUPERVISORS NAME : Bennett Fong LICENSING EVALUATOR NAME : Alicia Delmundo LICENSING EVALUATOR SIGNATURE : DATE: 06/04/2025 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office , 1515 CLAY STREET, STE. 310 OAKLAND , CA 94612 Page 3 Allegation: Staff is not providing appropriate assistance during transfers. FM1 stated she took R1 to the hospital in April 2023 where R1 was assessed and determined R1 needs a wheelchair. R1 was then upgraded to a tier two, which means R1 needs two people assistance during transfers. FM1 further indicated she has witnessed R1 being transferred by only one person “multiple times”. LIC602A Physician’s Report showed R1 as non-ambulatory, cannot bathe self and not able to care for own toileting needs. Incident reports dated 2/27/23, 4/07/23, 6/29/23, 7/14/23, 7/15/23, and 7/26/23 note R1 sustaining the same type of fall while the facility staff walked R1 to the bathroom. Therefore, the allegation is substantiated. Based on the Department’s interviews and records review conducted, the preponderance of evidence has been met, therefore the above allegations are found to be substantiated. Deficiencies are cited from Title 22 California Health and Safety Code and Regulations and listed on 9099Ds. A $1,000.00 civil penalty is assessed for deficiency section 1569.269(a)(6) which is also a repeat violation within 12 month period. Civil penalty for this deficiency will continue for $100.00 per day until corrected. Additional civil penalty may be assessed based on Health and Safety Code 1569.49(f ). Failure to submit proof of corrections by plan of correction due dates for the other deficiencies and any repeat violation within 12 month period may result in additional civil penalties. Deficiencies, civil penalty, and plan and proof of corrections were discussed with the ED. Exit interview conducted. Appeal Rights, LIC421IM Civil Penalty Assessment, LIC9098 Proof of Correction form and copy of this report provided. SUPERVISORS NAME : Bennett Fong LICENSING EVALUATOR NAME : Alicia Delmundo LICENSING EVALUATOR SIGNATURE : DATE: 06/04/2025 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office , 1515 CLAY STREET, STE. 310 OAKLAND , CA 94612 §1569.269 Enumerated rights; severability: (a) Residents of residential care facilities for the elderly shall have all of the following rights: (6) To care, supervision, and services that meet their individual needs and are delivered by staff.......... -This requirement is not met as evidenced by: Executive Director to do the following and submit proof by 6/05/25: 1. Revisit the facility's transfer procedures. 2. In-service the staff A $1,000.00 civil penalty is assessed. -Based on records reviews and interviews, the licensee did not comply with the section above in not meeting R1’s needs of being non-ambulatory by walking R1 to the bathroom causing R1 to fall and sustained injury which posed an immediate health, safety and/or personal rights risks to person in care. §1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (5) To be accorded safe, healthful, and comfortable accommodations....... -This requirement is not met as evidenced by Executive Director to in-service the staff and submit copy of training topic(s) with attendees signatures by 6/05/25. -Based on records review and interviews, the licensee did not comply with the section above in not safely meeting R1’s needs resulting to R1's constant falls which posed an immediate health, safety and/or personal rights risks to person in care. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. SUPERVISORS NAME : Bennett Fong LICENSING EVALUATOR NAME : Alicia Delmundo LICENSING EVALUATOR SIGNATURE : DATE: 06/04/2025 CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office , 1515 CLAY STREET, STE. 310 OAKLAND , CA 94612 87464 Basic Services (f) Basic services shall at a minimum include: (2) Safe and healthful living accommodations and services, as specified in Section 87307, Personal Accommodations and Services. -This requirement is not met as evidenced by: Executive Director to add to inservice training and submit copy of training topic(s) with attendees signatures by 6/05/25. -Based on records review and interviews, the licensee did not comply with the section above in not meeting R1’s transferring needs by walking R1 to the bathroom which posed an immediate health, safety and/or personal rights risks to person in care. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. SUPERVISORS NAME : Bennett Fong LICENSING EVALUATOR NAME : Alicia Delmundo LICENSING EVALUATOR SIGNATURE : DATE: 06/04/2025

During the course of investigation, LPA obtained copies of R1's Admission Agreement and document showing R1's move-out date which confirmed R1 moved-out on 05/04/2024. LPA also obtained copies of Authorization Agreement for Direct Payment (ACH) and payment records for R1. LPA interviewed FM on 01/21/2025 who stated he cancelled the automatic payment for 05/2024, somehow the payment still went through but the facility got the money before he cancelled the auto payment. FM further stated that he received a refund check of $7280.00 but when he deposited it, it bounced. On 01/29/2025, LPA received an e-mail from FM stating that it was a mistake on his end with the bank. LPA interviewed AED on 01/24/2025 who stated she is aware of issues regarding the refund and that the $7280.00 check refund was cancelled by MorningStar. AED called and spoke with FM on 02/06/2025 regarding the issue. The telephone call was followed by an email to FM confirming the communication between her and FM and that no balance is owed by either FM and facility. Based on information gathered, the allegation is closed as unfounded. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. No deficiency cited. Exit interview conducted and copy of this report provided.

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office , 1515 CLAY STREET, STE. 310 OAKLAND , CA 94612 This is an official report of an unannounced visit/investigation of a complaint received in our office on 09/01/2021 and conducted by Evaluator Bennett Fong -Facility staff did not administer medication to resident according to physician's instructions. -Resident sustained fall(s) resulting to injuries due to lack of supervision. -Staff did not safeguard resident's personal belongings. -Facility staff did not notify the resident's authorized representative of resident's injuries. On 3/8/25 at (time) LPM Jeremy Fong arrived unannounced to deliver the findings for the above allegations. LPM met with Community Relations Director, Henrietta Beshares, and informed her of the purpose of visit. During the course of investigation, the following resident’s documents were obtained: medical records; admission agreement; LIC601 Identification and Emergency Information; LIC602A Physician's Report; Pre-placement Appraisal; Reappraisals (2019, 2020 and 2021); LIC621 Client/Resident Personal Property and Valuables; LIC622 Centrally Stored Medication and Destruction Record; Medication Administration Records; incident reports (2019, 2020 and 2021). The Department also obtained copies of resident roster and staff schedule. Family member (FM), staff, medical providers (PCP, MD1 and MD2) and residents were interviewed on 10/2021, 12/2021, 1/19/2022, 8/2022 and 1/2023. Medical records and facility Call Button Log were reviewed. SUPERVISORS NAME : Pam Gill LICENSING EVALUATOR NAME : Bennett Fong LICENSING EVALUATOR SIGNATURE : DATE: 03/08/2025 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office , 1515 CLAY STREET, STE. 310 OAKLAND , CA 94612 Allegation: Facility staff did not administer medication to resident according to physician's instructions. Unsubstantiated. It was alleged that facility staff did not administer medication to resident (R1) according to physician's instructions. Reporting party (RP) stated R1 was admitted to the facility on 2016, and from 2016 to 2019, R1 was administered insulin. It was further alleged that the Humalog injection was discontinued on 2019, and facility retained R1 that the facility could no longer care for as R1 has diabetes and needs insulin. These dates are all prior to the current License for this facility issued on 10/09/2020. R1’s family member (FM) was interviewed who stated R1 was admitted to the facility 2016 and had (Humalog) insulin medication which facility discontinued to administer July 2019. FM received a bill in October 2019 that did not include R1’s insulin medications. FM indicated that staff S1 (facility’s registered nurse) told FM that as of October 2019, staff stopped giving R1 insulin injections. Review of records showed the facility sent request to R1’s primary care physician (PCP) to discontinue the Humalog sliding scale as Casa Sandoval scope of service does not allow the use of sliding scale insulin since non-clinical caregivers are assisting with the injections. PCP ordered Humalog sliding scale to be discontinued on July 24, 2019. When R1 was seen by PCP the After Visit Summary dated November 5, 2019 showed medications that were ordered to be continued included Humalog and Novolog. PCP indicated during interview on January 6, 2022 that during R1’s visit on November 5, 2019, R1 was still to be on insulin injections and nothing was changed with the dosages. However, it was not established that this information had been conveyed to the current Licensee. Hospice care was ordered for R1 and was started on November 22, 2019. Some medications were discontinued (dc’d) by hospice doctor (MD1), and while MD1 stated during interview that all medications would have been discontinued when the resident was placed on hospice, MD1’s list didn’t include Humalog and Novolog to be discontinued. November 2019 Medication Administration Record showed Humalog was not administered from 11/05/19 to 11/22/19, and Novolog was discontinued on November 22, 2019. R1 was discharged from hospice care June 20, 2020. These actions took place prior to the current License. Further, the PCP stated having had no knowledge of the resident being placed on hospice and changes made to the resident’s medication regimen. SUPERVISORS NAME : Pam Gill LICENSING EVALUATOR NAME : Bennett Fong LICENSING EVALUATOR SIGNATURE : DATE: 03/08/2025 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office , 1515 CLAY STREET, STE. 310 OAKLAND , CA 94612 Based upon interviews, records review, and conflicting information obtained, the Department has investigated this allegation and it could not be established that the current Licensee was made firmly aware that diabetic medications were to be continued and/or restarted. Although the allegation may have occurred or is valid, there is insufficient information to reach a preponderance of evidence. Therefore the allegation is Unsubstantiated. Allegation: Resident sustained fall(s) resulting to in injuries due to lack of supervision. Unsubstantiated. A review of the call button log from 6/1/2021 to 7/31/2021 showed 127 safety check-ins staff conducted on R1. R1 never pressed the emergency button to request staff assistance. None of the facility staff were aware R1 had sustained a fracture as R1 never complained of any pain, other than back pain from sitting in the recliner too long. Staff found out about the fracture when R1’s son, FM, reported it to the facility after R1’s hospitalization. During FM’s interview, FM stated R1 initially denied falling but later recalled she had and did not tell staff. A review of Hospital Discharge Summary stated R1 sustained a left femoral fracture from a fall. Orthopedist (MD2) confirmed R1’s fracture was due to a fall but was unable to tell whether the fracture was old or new. The Department interviewed R1 but R1 was unable to provide information. Based upon interviews, records review, and conflicting information obtained, the Department has investigated this allegation and determined that it could not be proven that R1s injuries were recent or new, nor that they were the result of insufficient care and supervision. Although the allegation may have occurred or is valid, there is insufficient information to reach a preponderance of evidence. Therefore, the allegation is Unsubstantiated. Allegation: Staff did not safeguard resident's personal belongings. Unsubstantiated. It was alleged that staff and other residents were taking R1 personal belongings such soda in R1 refrigerator and other items. SUPERVISORS NAME : Pam Gill LICENSING EVALUATOR NAME : Bennett Fong LICENSING EVALUATOR SIGNATURE : DATE: 03/08/2025 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office , 1515 CLAY STREET, STE. 310 OAKLAND , CA 94612 Staff (S1 and S2) were interviewed on 1/31/23 and 1/20/23. S1 stated she was not aware that R1 had soda in R1’s refrigerator. R1 was given Ensure and Ensure is labelled with resident’s name, and kept in medication cart. S2 indicated she never heard nor has anyone reported to her that R1's soda or other items are missing. It was never communicated to her by FM that R1's soda and other items were missing; otherwise, S2 will be involved and will the communicate with the staff. Missing items were never reported to them. Based upon interviews, records review, and conflicting information obtained, the Department has investigated this allegation and could not determine the factual accuracy that personal items had gone missing. Although the allegation may have occurred or is valid, there is insufficient information to reach a preponderance of evidence. Therefore, the allegation is Unsubstantiated. Allegation: Facility staff did not notify the resident's authorized representative of resident's injuries. Unsubstantiated. The Department interviewed FM and staff. During FM’s interview, FM stated R1 initially denied falling but later recalled she had and did not tell staff. R1 was interviewed and stated her leg problem was due to old age. Staff (S1, S3, S4, S5, S6, S7, S8 and S8) were interviewed on 12/08/21, 12/16/21, 12/30/21. These staff stated R1 didn’t complain of pain, not being aware that R1 had fallen and sustained fall. S1 stated she was not aware R1 had fallen and sustained a fracture. S1 indicated she came to know after R1 was hospitalized. Based upon interviews, records review, and conflicting information obtained, the Department has investigated this allegation and could not establish that facility staff had been aware of, and/or, informed that R1 had sustained a fall prior to going to hospital, nor whether the fracture found was recent or old. Although the allegation may have occurred or is valid, there is insufficient information to reach a preponderance of evidence. Therefore, the allegation is Unsubstantiated. Exit interview conducted and a copy of this report was provided. SUPERVISORS NAME : Pam Gill LICENSING EVALUATOR NAME : Bennett Fong LICENSING EVALUATOR SIGNATURE : DATE: 03/08/2025 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

On this day, January 27, 2026, Licensing Program Analyst (LPA) Delmundo conducted a case management visit in response to the Unusual Incident Report (UIR) submitted by the facility for resident (R1) which LPA received on January 20, 2026. UIR indicated that on January 19, 2026, R1 had unwitnessed fall and was found lying on the floor on her side and was noted with bleeding to the right cheek. 9-11 was contacted and R1 was sent out, family member and R1's primary care physician were informed. R1 returned to the facility with stitches to the laceration. On this same day, January 27, 2026, LPA interviewed R1 who stated she rushed in wheeling her wheelchair resulting to falling out. No deficiency cited. Exit interview conducted and copy of this report provided.

Review of email communication between staff (S1) and FM showed FM has been following-up on the refund. Email threads between FM and S1 showed FM has been following-up since September 2024. On 1/03/25, FM sent another email to S1 stating FM was having issues with S1 getting back to FM and that S1 was asked for the best way to contact S1 which S1 said via email. On 1/04/25, S1 responded to FM stating the ED who was included on the previous emails no longer work at the facility but will have the IED give FM a call on 1/06/25. LPA interviewed the IED who stated though she is aware of the refund issues, she does not know the details. IED stated she didn't call nor send email to FM. Based on information obtained, the preponderance of evidence standard has been met, therefore, the allegation is substantiated. Deficiency is cited per Title 22 California Code of Regulations, and listed on LIC9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violation within 12 month period may result in civil penalty. Deficiency and plan and proof of correction were discussed with the IED. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.

LPA interviewed 7 staff. One of these staff stated she does not administer injection; however, when she told the resident that this resident needs to do it herself, this resident told her that the other med-tech does it. One of the med-techs stated she's not a medical professional nor an LVN but she pricks for glucose tests and administers insulin to 3 residents. Based on interviews and records review, the preponderance of evidence has been met, therefore, the allegation is substantiated. Deficiency is cited from Title 22 California Code of Regulations and listed on 9099D. Failure to submit proof of correction by plan of correction due date may result in civil penalty. Deficiency and plan and proof of corrections were discuss with AED. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office , 1515 CLAY STREET, STE. 310 OAKLAND , CA 94612 This is an official report of an unannounced visit/investigation of a complaint received in our office on 03/19/2024 and conducted by Evaluator Alicia Delmundo -Facility failed to seek medical attention for resident (R1) in timely manner. -Facility improperly assisted resident (R1) with medical needs. -Staff not responding to responsible person's request for communication regarding resident's (R1) care and services. -Staff interfere with residents' mail. On this day, 1/16/25, at 12:00 noon, Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the investigation of the above allegations and close the complaint. LPA met with Associate Executive Director (AED) Rosana Frias. and informed the reason for visit. During the course of investigation, LPA obtained copies of staff schedule and resident roster. LPA obtained copies of including but not limited to the following: LIC601 Identification and Emergency Contact Information; LIC602A Physician's Reports; doctor's orders of medications; Medication Administration Records (MAR); LIC622 Centrally Stored Medication and Destruction Records; doctor's orders of medicaitons; facility notes; blood pressure log; facility's records of communication with Pine Park Health and R1's responsible person (FM). LPA interviewed staff (former ED, AED, S1, S2, S3, S4, S5, S6, S7) on 3/22/24 and 1/16/25, obtained information from FM on 5/22/24, interviewed residents (R2, R3) on 1/16/25 and obtained information from Pine Park Health staff (PP1). ....continued on 9099C (page 2) SUPERVISORS NAME : Bennett Fong LICENSING EVALUATOR NAME : Alicia Delmundo LICENSING EVALUATOR SIGNATURE : DATE: 01/16/2025 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office , 1515 CLAY STREET, STE. 310 OAKLAND , CA 94612 Page 2 Allegation: Facility failed to seek medical attention for resident (R1) in timely manner. Reporting party (RP) stated that R1 has doctor's order to monitor blood pressure (BP) and was prescribed medication back in 2022. RP further stated that on 2/19/24, Pine Park Nurse Practitioner (W1) called R1's responsible person (FM) and told FM that R1 will be sent out due to the BP being out of control. RP alleged that facility did not call 9-1-1. LPA reached out to W1 but W1 did not return LPA's call. PP1 confirmed W1 has an order sent to the facility to check R1's blood pressure from 2/07/24 to 2/14/24. Review on Unusual Incident Report showed staff (S1) called 9-1-1 on 2/19/24 and that W1 was notified and that FM was aware. LPA interviewed S1 who confirmed she called 9-1-1 and that R1 was sent out due to high blood pressure. Based on information gathered and LPA unable to obtain information from W1, and LPA not able to interview R1 due to R1's medical diagnosis of R1, the allegation is unsubstantiated. Allegation: Facility improperly assisted resident (R1) with medical needs. It was alleged that R1's urine sample was sent by the facility to a different laboratory other than Pine Park Health. Review of record showed order for urinalysis. Review of facility notes, communication with Pine Park Health and FM showed that FM was informed about the urine sample. LPA interviewed the Wellness Director and S1 who stated that Pine Park has third party, Labcorp and GTI, that picks-up the urine sample. LPA tried to reach W1 but W1 did not return LPA's call. Therefore, the allegation is unsubstantiated. ...continued on 9099C (page 3) SUPERVISORS NAME : Bennett Fong LICENSING EVALUATOR NAME : Alicia Delmundo LICENSING EVALUATOR SIGNATURE : DATE: 01/16/2025 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office , 1515 CLAY STREET, STE. 310 OAKLAND , CA 94612 Page 3 Allegation: Staff not responding to responsible person's request for communication regarding resident's (R1) care and services. RP stated that staff S2 opened R1's mail and that FM wants to know what's going on and requested to have a meeting/discussion with former Executive Director (ED). The ED told FM she will look on it. FM had a phone conversation on January 6, 2024 regarding the issues and concerns FM brought up but never got a response/answer from former ED. LPA interviewed former ED who stated she talked to FM a lot over the phone, one was on 11/28/23 for 39 minutes, on 12/20/23 for 15 minutes, and for 16 & 20 minutes on 1/03/24. S1 also provided FM updates via phone calls and text messages. Copies of text messages, proof of phone calls obtained by LPA confirmed former ED's statements. LPA interviewed S1 who stated she communicated and provided updates to FM. S2 stated she communicated with FM via email, text & phone calls and has got into a point where FM communicated and called the staff daily. S1 also stated that they set up a weekly schedule which FM agreed, and assigned S1 and she (S2) will step up if S1 is not available to speak with FM. S2 stated that iff S1 is not available, FM will S2, the former ED and that FM also calls outside the weekly schedule. Based on information obtained, the allegation is unsubstantiated. Allegation: Staff interfere with residents' mail. It was alleged that R1's mail was opened by staff. S2 stated when she went to R1's apartment on 12/2023 to check on R1, she observed a correspondence pertaining to insurance which need to be renewed by 01/2024, so she sent the picture of the correspondence to FM which LPA obtained a copy of the text message and correspondense. S1 denied opening R1 or any of residents' mail and stated she does not have key to R1's mailbox. LPA interviewed other staff (S1, S2, S3, S4, S5, S6 and S7) who all denied opening residents' mail. AED stated not observing staff opening residents mail nor was brought to her attention. LPA also interview residents (R2 and R3) who stated their mail were never opened by staff. Therefore, the allegation is unsubstantiated. ......continued on 9099C (page 4) SUPERVISORS NAME : Bennett Fong LICENSING EVALUATOR NAME : Alicia Delmundo LICENSING EVALUATOR SIGNATURE : DATE: 01/16/2025 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office , 1515 CLAY STREET, STE. 310 OAKLAND , CA 94612 Page 4 Based on interviews, records review, and LPA unable to obtain information from W1 and R1, the 4 allegations are closed as unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiency cited. Exit interview conducted and copy of this report provided. SUPERVISORS NAME : Bennett Fong LICENSING EVALUATOR NAME : Alicia Delmundo LICENSING EVALUATOR SIGNATURE : DATE: 01/16/2025 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

During inspection, LPA observed roach traps with dead roaches in 2 residents apartments. LPA also observed dead roach in the kitchen cabinet in 1 of the apartments and stained carpet flooring and mattress leaning on the wall in this apartment, and another apartment with litter. Based on interviews and observation, the preponderance of evidence has been met, therefore, the allegation is substantiated. Deficiency is cited from Title 22 California Code of Regulations and listed on 9099D. A $250.00 civil penalty is assessed for repeat violation of section 87303(a) within 12 month period. Failure to submit proof of correction by plan of correction due date may result in additional civil penalty. Deficiency and plan and proof of correction were discuss with AED. Exit interview conducted. Appeal Rights, LIC421FC Civil Penalty Assessment, LIC9098 Proof of Correction form and copy of this report provided.

While at the facility for other reason, Licensing Program Analyst (LPA) Delmundo learned that the facility's new administrator/executive director is Nanensila 'Nancy' Randhawa. LPA verified, and Ms. Randhawa stated she started on April 7, 2025. LPA discussed the Title 22 Regulations pertaining to hiring a new administrator. LPA received on this same day copies of the following: 1. Ms Randhawa's LIC501 Personnel Record, resume and administrator certificate 2. LIC308 Designation of Facility Responsibility 4. LIC500 Personnel Report 5. Board letter Exit interview conducted and copy of this report provided.

UIR indicated that at 1:30 am on 1/14/23, R1 was found on the floor of his room, was breathing but unable to be awaken. 9-1-1 was called and R1 was transported to the hospital. Hospital Discharge Summary showed diagnosis of alcohol intoxication among others with alcohol level of 244 on arrival, and that R1 stated he drinks ‘too much’ Vodka. On 1/19/23, LPA interviewed staff (S1 and S2) and R1’s current conservator (C1). S2 confirmed the incident happened on 1/14/23. S1 stated R1 is allowed 1 drink of travel size of Vodka of about 2 oz/day, but it doesn’t mean R1 will not ask for more and if not given, R1 will become belligerent. C1 stated that when he visited R1 one morning, C1 observed a stain in the carpet in R1’s room on which the staff stated that it’s alcohol. Review of records showed R1’s former conservator (C2) gave permission to the facility to purchase Vodka, not to give all at once and only let R1 consume 1 small bottle at night only. Facility's Alcohol Intake Records for R1 showed R1 was given from 2 to 3 times in the evening of which each time R1 was given 2 to 4 cups of 5 oz/cup. Records also showed there were days when R1 was given 5 oz at 1:00 am, 1:20 am, 1:30 am, 2:30 am and on those days, R1 was also given at night. Based on information gathered, the preponderance of evidence is met, therefore, the allegation is substantiated. Deficiency is cited from Title 22 California Code of Regulations and listed on 9099D. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12-month period may result in civil penalty. Deficiency and plan and proof of correction were discussed with the AED. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and 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 UIR indicated that at 1:30 am on 1/14/23, R1 was found on the floor of his room, was breathing but unable to be awaken. 9-1-1 was called and R1 was transported to the hospital. On 1/19/23, LPA interviewed staff (S2) who confirmed the incident that happened on 1/14/23. Review of LIC602A Physician’s Report revealed R1 does not need assistance with feeding. LPA was unable to interview R1. Based on all information obtained and due to LPA was not able to obtain information from R1, the allegation is unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. No deficiency cited. Exit interview conducted and copy of this report provided.

Allegations: -Facility is isolating residents. -Facility is not providing activities for the residents. R1 stated the facility dining and activity rooms were closed and does not understand why the facility was quarantined. The other 2 residents (R2 and R3) stated they were not bothered when dining and activity rooms were closed during the outbreak and R3 stated it is for the health and safety of everyone. Staff (S1) stated the dining and activity were closed per recommendation by Public Health. Review of information obtained from AED showed that it was the LPH recommendation to close the dining and activity room during outbreak. Allegation: Facility is delivering residents meals cold. R1 stated the food delivered to his room was cold. S1 stated that during outbreak, meals were delivered to each of the resident in their room. Some of the residents were still sleeping when meals were delivered and caregivers warm their food when residents were ready to eat. R2 stated if her food was cold, it’s not a problem as caregiver warms it. R3 stated sometimes the food was not warm but it’s not a problem because he can warm it in his microwave. Based on all information gathered, the above allegations are close as unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. No deficiency cited. Exit interview conducted and copy of this report provided.

Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management visit in response to the Unusual Incident Report (UIR) submitted by the facility. UIR indicated that at 12:26 p.m. on February 8, 2024, Reflections Coordinator (S1) was notified by care manager (staff) that there were discrepancies with residents' narcotic medications. After S1 confirmed that the medications in the containers were incorrect, S1 reported to the Wellness Director (WD) who in turn reported to Executive Direction (KED) Cayia Henry. WD and ED immediately launched an investigation and in-service on narcotic count and recognition initiated to all med-techs. ED notified Local Law Enforcement, and Controlled Substance Count documented. On this day, March 22, 2024, LPA conducted interview and obtained copies of documents. No deficiency cited. Exit interview conducted, and copy of this report provided.

During investigation of complaint (Control # 15-AS-20240319155109), Licensing Program Analyst (LPA) was provided the following information: 1. Pine Park Health sent order to the facility to check resident's (R1) blood pressure (BP) from 02/07/2024 to 02/14/2024. Information obtained from Pine Park Health staff confirmed there's an order. However, review of R1's record and staff record sent by staff to Pine Park Health showed R1 refused blood pressure check on 02/14/2024 and BP record from 02/16/2024 to 02/19/2024. There's was no record for 02/07/2024 to 02/13/2024. LPA interviewed S1 who was not able to provide information why R1's BP was not checked for the said ordered dates. 2. R1 had overgrown toenails. Pictures obtained by LPA showed R1 had discolored overgrown toenails about 1 to 2 inches long. LPA called the podiatrist clinic who confirmed R1 was seen in 4/2024 Deficiencies are cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of corrections by plan of correction dates and any repeat violation within 12 month period may result in civil penalty. Deficiency and plan and proof of correction were discussed with AED.

On this day, 12/22/23, Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the annual required inspection that was started on 10/04/23. LPA met with Executive Director (ED) Cayia Henry, and informed the reason for visit. LPA reviewed 5 residents records. LPA checked the medications and compared with doctor's orders and LIC622 Centrally Stored Medication and Destruction Records. Facility does not handle residents' cash resources. No deficiency cited. Exit interview conducted and copy of this report provided.

On this day, 12/15/2023, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct case management as a follow-up on the Death Report received by the Department on 12/11/23. Report indicated that when caregiver (S1) arrived at R1's apartment to assist with feeding for dinner, S1 noted that R1 was unresponsive. Med-tech (S2) was gathering vital signs and noted that there was no pulse noted. Wellness Nurse (S3) called 9-1-1 and called the closest kin. Report also indicated that R1 returned to the facility on 12/08/23 from post acute. LPA obtained copies of including but not limited to the following documents: Notice of Transfer/Discharge from post acute; LIC602A Physician's Report; LIC9172 Functional Capability Assessment dated 12/08/23; Progress Notes, LPA conducted interviews. No deficiency cited on this day, Exit interview conducted and copy of this report provided.

On this day, 12/22/2023, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management as a follow-up on the Death Reports and Unusual Incident Reports (UIRs) received by the Department. LPA met with Executive Director (ED) Cayia Henry, and informed the reason for visit. Reports indicated the following: 1. Resident (R1) Death Report Report indicated R1 passed away on 5/09/23 with cause of death unknown. R1 was previously sent to the hospital for increased confusion and complaints of left hip pain. R1 expired at the hospital. R1's son called the facility to inform that R1 passed away.. 2. Resident (R2) Death Report Report indicated R2 passed away on 7/17/23. R2 was found unresponsive, no pulse noted and pale in color. Med-tech on duty called 9-1-1 right away. R2 had a fall on 7/10/23 but refused to paramedics to be transferred to ER. R2 refused paramedics again on 7/12/23; was sent via 9-1-1 for an x-ray appointment on 7/14/23, but refused to stay in the hospital for treatment. R2 again refused to be sent out on 7/16/23 due to distended abdomen, 3. Resident (R3) Unusual Incident Report (UIR) UIR indicated R3 had un-witnessed fall on 12/23/23 and was noted with a bump on the side of R3's head and abrasion on the left knee. 9-1-1 was called and R3 was taken to the hospital. Family member, primary care physician and facility's Wellness Director notified. 4. Resident (R4) UIR UIR indicated R4 was seen lying on the floor screaming for help and complaining of pain of left side of leg and head. R4 was conscious and responsive. 9-1-1 was called and R2 was taken to the hospital. Family member, primary care physician and facility's Wellness Director notified. 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 reviewed residents' files and obtained copies of documents including but not limited to the following: LIC601 Identification and Emergency Contact Information; LIC602A Physician's Report; Appraisal; facility notes; Post-fall Evaluation; hospital discharge documents. LPA conducted interview. Deficiencies are cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of corrections by plan of correction of due dates may result in civil penalties. Deficiencies and plan and proof of correction were discussed with ED. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.

On this day, August 3, 2023, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a health and safety inspection as a result of the Department receiving a priority 1 complaint (Complaint # 15-AS-20230801150316). LPA met with Business Office Specialist Maria David who called Operations Regional VP Phii Atlman. LPA informed the reason for visit. LPA toured the facility with Maria David. LPA inspected the 1st, 2nd, 3rd, 4th and 5th floors including but not limited to common areas and dining room and activity areas on the 1st and 2nd floors, salon, housekeeping, electrical and art rooms, patio. LPA randomly selected total of 12 residents apartments on 2nd, 3rd, 4th and 5th floors, LPA observed the following: -at 1:03 pm, cuticle remover, scissors, Tide Ultra Concentrated Liquid Soap, cleaning and salon supplies in cabinets/drawers without lock in unlocked salon on the 1st floor. -at 1:07 pm. professional strength glue, scissors, paint spray, fabric and vinyl adhesive spray in cabinets without lock in unlocked art room. -at 1:12 pm, cleaning supplies in unlocked housekeeping room on the 2nd floor. -at 1:30 pm and 1:50 pm, "Oxygen in Use" sign on resident's apartments doors on the 3rd floor. -at 3:00 pm, resident (R1) does not have LIC602A Physician's Report and Pre-admission Appraisal on file. LPA verified and two staff confirmed R1 does not have these documents. ......continued on 809C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 -at 3:10 pm, LPA also observed R2's Lic602A Physician's Report indicated R2 has dementia but can administer own medications but doctor's notes with same date as that on LIC602 showed R2 can not determine needs for medications. Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates may result in civil penalties. Deficiencies and plan and proof of corrections were discussed with Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.

The preponderance of evidence has been met, therefore, the allegation is substantiated. A $250.00 civil penalty is assessed for repeat violation of Regulation section # 87309(a). First and second citations were issued on 8/03/23 and 10/04/23. Allegation: Facility staff working in the kitchen do not observe food services sanitation practices. LPA observed 2 kitchen staff (KS1 and KS2), one peeling a pineapple and one doing the dishes with both with long hair not wearing hairnets. Although both staff had their hair tied back, one of the staff's hair dangling. Based on information obtained, the preponderance of evidence was met, therefore, the allegation is substantiated. Deficiencies, plan and proof of corrections and civil penalty were discussed with ED. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form, LIC421FC Civil Assessment, and copy of this report provided. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation: Facility inappropriately serving alcohol to residents. List of Activities includes Happy Hour once a week. ED stated Happy Hour is open to all residents; however, not a lot of residents come. There's residents who regularly join the Happy Hour and the staff who serve during Happy Hour has list of residents who are not to be given alcohol per doctor's order. If they are not sure, they give the resident a "mock cocktail". If there's a new resident who wants alcohol. the staff check with the doctor first; this statement was observed by LPA during Happy Hour as one ot the staff informed 1 of the resident. LPA interviewed the 3 staff, 2 of which stated they only serve alcohol to those who are on the list to be given. The staff only give maximum of 2 small cups which was confirmed by LPA upon observation. LPA reviewed 1 of the resident who is on the list allowed to be given alcohol, Record showed this resident does not have order from the doctor prohibiting the resident from alcohol consumption. Allegation: Staff drinking alcohol while at the facility. It was alleged that 3 staff (S1, S2 and S3) drink alcohol when at the facility. LPA interviewed S1, S2 and S3 who all denied the allegation. LPA interviewed other 7 staff, 6 of which stated not observing S1, S2 and S3 drinking alcohol when at the facility. LPA also interviewed 1 of residents family member who stated not observing any staff drinking alcohol. Based on all information gathered, the 3 allegations are unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiency cited. Exit interview conducted, and copy of this report provided.

Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management in response to the Unusual/Injury Incident Reports (UIRs) for residents (R1, R2, R3 and R4) submitted by the facility to the Department. LPA met with Associate Executive Director Rosana Frias and informed the purpose of visit. LPA also met and spoke with Wellness Director/LVN Valentine Mathangani. UIRs indicated the following: 1. Resident (R1) October 1, 2021 - Home health was providing routine wound care to R1. Wound not improving. Wound was cleansed and treated by the nurse before resident was transferred to the hospital for further evaluation. R1 remains out of the community at the time of the report. 2. Resident (R2) September 25, 2021 - case manager checked at around 5:30 pm and found R2 unresponsive. 9-1-1 was activated and R2 was transported to the hospital. R2 was discharged back to the facility with no new orders; frequent checks initiated 3. Resident (R3) October 3, 2021 - R3 called Hayward Police Department (HPD) for assistance at around 3:30 am, because R3 wants to go to the hospital and talk to her doctor. HPD took R3 to John George. Case manager and R3's physician were notified. 4. Resident (R4) October 1, 2021 - R4 was noted to have swelling on face and puffy eyelids. Staff called 9-1-1 and R4 was brought to the emergency. R4's POA and physician notified. .....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 LPA conducted interviews and obtained the following documents for R1, R2, R3 and R4: LIC602A Physician's Report; Appraisal; hospital discharge document. LPA also obtained copies of home health visit notes for R1. According to Rosana Frias and Valentine Matangani, R1 and R4 did not return to the facility. LPA to review the documents obtained. A follow-up visit will be conducted if warranted. No deficiency cited during today's visit. Exit interview conducted and copy of this report provided.

Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct case management as a follow-up on the Unusual Incident Report (UIR) received by the Department. UIR indicated that on October 19, 2022, staff checked on resident (R1) in room and common areas around 9:10 am, and unable to locate R1. Staff immediately activated code silver. Executive Director checked the camera monitor and saw R1 leaving around 9:00 am. Staff followed the route R1 headed, and found R1. R1 was not on apparent distress. LPA requested for copies of LIC602A Physician's Report which revealed R1 has dementia and wandering and sundowning behaviors, and can not leave the facility unassisted. On this day, LPA observed the front door entrance's auditory device not working. Deficiendies cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections (POCs) by plan of correction due dates, and any repeat violations within 12 month period may result in civil penalties. Deficiency and plan and proof of correction were discussed with Rosana Frias. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.

Continued from LIC9099. Interviews with R2, R4, and R5 indicated they have felt safe during the renovation and the elevators have been working normal. LPA observed residents walking outside in common area and it didn't appear the scaffolding was obstructing or unsafe for the residents. LPA also timed the elevator from one floor to another when button was pushed. It took 30 seconds for the elevator to come from the 2nd floor to the 1st floor. LPA observed 3 elevators throughout the facility. Residents in care appear to be safe and there are no imminent health/safety concerns on today's date. Based upon the interviews and observations during the investigation the above allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and a copy of report was given.

Licensing Prog ram Analyst (LPA) Delmund conducted an unannounced infection control annual inspection. LPA met with Associate Executive Director (AED) Rosana Frias and informed the purpose of visit. Facility is a seven story building, 2nd and 3rd floors of which house assisted living residents. Facility has a completed COVID-19 mitigation plan that was approved on April 12, 2021. LPA inspected the facility inside and out with Rosana Frias. LPA observed screening station located near the front entrance with visitor's log, hand sanitizer and no touch temperature probe; surgical masks and disposable gloves are readily available at the front desk. . Routine symptom screening (+/-) temperature and symptom checks are done at entry for all staff and visitors. Residents are screened for COVID-19 symptoms and temperature checked daily. LPA observed COVID-19 physical distancing signages posted in common areas. Infection control designated leader is the wellness coordinator. Medications are centrally stored in the medication room attended by med-techs, wellness coordinator and wellness director. Adequate supply of centrally stored PPEs was observed. There were at least 7 days of nonperishable and 2 days of perishable foods. Facility maintains daily log of freezer temperature. Fire extinguisher in the kitchen was observed fully charged and tag showed serviced March 29, 2021. Smoke and carbon monoxide detectors were operational. Facility room temperature was tested and measured at 69 degrees Fahrenheit. LPA randomly selected 5 resident rooms on the second floor and 5 resident rooms on the third floor for inspection. ......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 LPA observed the following: 1. Three cans of gallon size expired prunes (expiration date: June 2020) and 1 of the cans was rusted. 2. No handwashing signage in the bathrooms and trash cans with no lids in resident's rooms including the shared room. 3. No updated visitor's poster on the entrance door. 4. No cough and sneeze etiquette posters. LPA requested for copies of the following updated documents to be submitted to Community Care Licensing (CCL) by November 3, 2021: 1. LIC500 Personnel Report 2. LIC308 Designation of Facility Responsibility 3. LIC610E Emergency Disaster Plan 4. Proof of $3M liability insurance coverage Deficiency is cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of correction by plan of correction due date and any repeat violations within 12 month period may result in civil penalty. Deficiency and plan and proof of correction were discussed with Rosana Frias. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.

Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct health and safety inspection as a result of the Department receiving a complaint (Control # 15-AS-20210901144412). LPA met with Assisted Living Coordinator Vivian Valeros and informed the purpose of visit. Vivian called Associate Executive Director Rosana Frias who arrived after twenty (25) minutes. LPA started the inspection with Vivian Valeros and Activity Director Ricky Dulay and continued with Rosana Frias. LPA inspected the common areas on the ground floor, kitchen, dining room and patio. LPA randomly selected for inspection 4 resident rooms on the second floor and 4 resident rooms on the third floor. LPA observed the following: 1. Patio - snail and slugs killer and garden bugs killer spray; uneven pavement by the dining room exit door; pieces of construction metal 2. Second floor - frayed carpet flooring by entrance door in one of the resident's rooms. 3. Third floor - bathroom doors in one of the resident's rooms. Deficiency is cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of correction by plan of correction due date and any repeat violations within 12 month period may result in civil penalties. Deficiencies and plan and proof of corrections were discussed with Rosana Frias. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.