Ivy Park at Hayward.

On this day, May 26, 2026, Licensing Program Analyst (LPA) Delmundo conducted a health and safety inspection as a result of the Department receiving a Priority 2 complaint (Complaint Control # 15-AS-20260522142733). LPA met with Executive Director (ED) Joseph Vilanueva and informed the reason for visit. LPA toured the facility with ED. LPA inspected the dining area on the first floor, art room, activity area. Salon and housekeeping and supplies rooms on the first floor were observed locked. Dining and activity rooms on the second floor were also inspected. Laundry rooms on other floors were checked and observed locked. Hot water temperature in the bathroom of one of the resident's apartments was tested and measured at 114 degrees Fahrenheit. LPA randomly selected 7 residents apartments for inspection - 1 each on 1st, 3rd, 4th floors, and 2 on 2nd and 5th floors. LPA observed the following: -at 12:02 pm, 2 pairs of scissors unlocked in the art room. -at 12:17 pm, wound cleanser, scissors, Neosporin in the dining table and Lysol cleaning agent in the bathroom in one of the resident's apartments. - at 12:18 pm, dirty/soiled carpet flooring in one the resident's apartments. -at 12:27 pm and 12:33 pm, heavily spoiled carpet flooring in other 2 residents' apartments. .....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 Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. A $250.00 civil penalty is assessed for repeat violation within 12 month period for deficiency section # 87309(a). Failure to submit proof of corrections by plan of correction due dates may result in additional civil penalty. Deficiencies and plan and proof of corrections were discussed with the Executive Director. Exit interview conducted. Appeal Rights, LIC421FC Civil Penalty Assessment, LIC9098 Proof of Correction form and copy of this report provided.

Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management in response to Unusual Incident Report (UIR) the facility submitted. LPA met with Executive Director (ED) Joseph Villanueva and informed the reason for visit. UIR indicated that approximately 3:36 pm on February 28, 2026, resident (R1) was observed returning to the community from outside. Surveillance footage was reviewed and determined that R1 had left the facility unassisted through the main entrance door at approximately 2:58 pm. R1 cannot leave the facility unassisted. On this day, LPA obtained copies of resident roster and staff schedule. LPA inspected the entrance/exit doors with ED, conducted interviews and reviewed and obtained copies of R1's including but not limited to the following documents: Resident Information Form; LIC602A Physician's Report; Mini-Mental State Examination; Individualized Service Plan ED stated that at the time R1 left the facility, R1 was in Assisted Living. After the incident, R1 was provided 1:1 caregiver until R1 moved to Memory Care Unit about 2 week ago. ED also stated that the time the incident happened, the concierge/front desk staff left for few minutes. Deficiency is cited from Title 22 California Code of Regulations and listed on 809D. Any repeat violation within 12 month period may result in civil penalty. Deficiency was discussed with the ED. Exit interview conducted. Appeal Rights 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.

At 1:45 pm on this day, 10/30/25, Licensing Program Analyst (LPA) Alicia Delmundo conducted an unannounced annual required inspection. LPA met with Executive Director (ED) Joseph Villanueva and informed the reason for visit. Facility is a seven story building, of which 1st floor to 5th floors house assisted living residents. LPA toured the facility with ED. LPA inspected the common areas, activity rooms, kitchen, dining rooms on the first and 2nd floors, Life Enhancement area, lounge/bistro. theater, fitness center/room, courtyard and back patio. Salon, housekeeping and supplies rooms, art studio, massage/therapy room and fitness center on the first floor were inspected. Electrical and housekeeping supply rooms, laundry rooms on other floors were checked. Food supplies were observed good for 7 days of non perishables and 2 days of perishables. LPA randomly selected 10 residents apartments for inspection - 2 each on 1st, 2nd, 3rd, 4th and 5th floors. Facility has carbon monoxide and smoke detectors that are in operating condition. Hot water temperature in one of the residents' bathroom on the 2nd floor was tested and measured at 117.1 degrees Fahrenheit. Facility has evacuation chairs on stairwells. Facility conducts disaster drills at least every quarter and records showed last fire, disaster and earth quake drills last conducted 9/26/25, 9/24/25 and 10/29/25 respectively. ....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 LPA observed the following: -at 2:30 pm, razor in the bathroom of 1 of the apartments in memory care unit. -at 2:55 pm, Tylenol in the medicaiton cabinet in the bathroom of the resident on the 4th floor of which the LIC602A Physician's Report showed can not administer and store own medications The following updated/current documents to be submitted by November 13, 2024: 1. LIC308 Designation of Facility Responsibility 2, LIC500 Personnel Report 3. LIC610E Emergency Disaster Plan (9 pages) 4. $3M Liability Insurance certificate 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 ED. Due to time constraint, LPA will come back to continue inspection. 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.

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) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Page 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.

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.

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.

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.

Licensing Program Analyst (LPA) Alicia Delmundo conducted an unannounced annual required inspection. LPA met with Associate Executive Director (AED) Rosana Frias, and informed the reason for visit. Facility is a seven story building, the 2nd, 3rd, 4th and 5th floors of which houses assisted living residents. Facility has LIC9282 Infection Control Plan, and updated copy provided to LPA on this same day. LPA inspected the facility inside and out with AED. LPA inspected the common areas, activity rooms, kitchen, dining rooms, Life Enhancement area, lounge/bistro. theater, fitness center/room, courtyard and back patio. Salon, housekeeping supplies room, massage/therapy rooms on the first floor were inspected. Electrical and housekeeping supplies rooms, laundry rooms on other floors were checked. Food supplies were observed good for 7 days of non perishables and 2 days of perishables. Freezers and refrigerators temperatures are checked by kitchen staff and records kept and observed within Regulations range. LPA randomly selected 10 residents rooms for inspection - 4 rooms on 2nd floor, 2 rooms on the 3rd floor, and 3 rooms each on 4th and 5th floors. Facility has carbon monoxide and smoke detectors that are in operating condition. Hot water temperature in one of the residents' bathroom on the 3rd floor was checked and measured at 114.6 degrees Fahrenheit. Fire extinguisher in the kitchen was observed fully charge with tag showed serviced April 4, 2024. Facility has evacuation chairs on stairwells. Facility conducts disaster drills and records showed last conducted August 26, 2024. LPA reviewed 5 staff and 6 residents files, and interviewed 4 residents. ....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 LPA observed the following: -at 1:44 pm, razor, hair developer, perming agent, waving lotion, anti fungal wash and screw driver in unlocked drawers in unlocked salon. -at 2:09 pm, Peritoneal cleanser in the resident's room in Memory Care Unit. -at 2:37 pm, stained/soiled carpet flooring in resident's room on the 3rd floor. -at 2:40 pm, resident (R3) has medications in the bathroom. R3's LIC602A indicated dementia. LPA verified, and per Wellness Director, R3 is on facility's Medication Program. -at 2:57 pm, cleaning supplies in unlocked housekeeping room on the 5th floor. -at 3:05 pm, stained/soiled carpet flooring in resident's room on the 5th floor. -at 4:45 pm, staff (S3) does not have the 20 total hours of required training for 2023. -at 5:20, staff (S1 and S5) has not completed the required 40 hours of training. S5 has not completed the required total initial hours of medication training. -at 6:00 pm, residents (R2 and R4) has postural support (halo; half bed rails) but no doctor's orders on file. The following updated/current documents to be submitted by October 10, 2024: 1. LIC308 Designation of Facility Responsibility 2, LIC500 Personnel Report 3. LIC610E Emergency Disaster Plan (9 pages) 4. $3M Liability Insurance certificate Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. A $250.00 civil penalty is assessed for repeat violation of section 87309(a) within 12 month period. Failure to submit proof of correction by plan of correction due date may result in additional civil penalty. Deficiencies and plan and proof of corrections were discuss with AED. Due to time constraint, LPA will come back to continue inspection. Exit interview conducted. Appeal Rights, LIC421FC Civil Penaly Assessment, LIC9098 Proof of Correction form 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.

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) Alicia Delmundo conducted an unannounced annual required inspection. LPA met with Executive Director (ED) Cayia Henry, and informed the purpose of visit. Facility is a seven story building, 2nd, 3rd, 4th and 5th floors of which houses assisted living residents. Facility has an LIC808 Mitigation Plan on file; however, Infection Control Plan on facility file was dated January 2020, and needs updating. LPA inspected the facility inside and out with ED. LPA inspected the common areas, activity rooms, kitchen, dining rooms, courtyard and back patio. Salon, housekeeping supplies room, massage/therapy rooms on the first floor were inspected. Electrical and housekeeping supplies room on other floors and laundry room were checked and observed locked. Food supplies were observed good for 7 days of non perishables and 2 days of perishables. Freezers and refrigerators temperatures are checked by kitchen staff and records kept. LPA observed the freezer and refrigerator temperatures were at -7.0 and 35 degrees Fahrenheit respectively. LPA randomly selected 8 residents rooms for inspection - 2 each on 2nd, 3rd, 4th and 5th floors. Facility has carbon monoxide and smoke detectors and observed functional. Hot water temperature in one of the resident rooms on the 2nd floor was tested and measured at 116.8 degrees Fahrenheit. Fire extinguisher in the kitchen was observed fully charge with tag showed serviced August 28, 2023. Facility has evacuation chairs on stairwells. Facility conducts disaster drills for all shifts every quarter. and records showed last conducted September 26. 2023. LPA reviewed 5 staff files, and interviewed 4 staff and 4 residents. .......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 LPA observed the following: -at 12;05 pm, blade and scissors in the drawer without lock in unlocked salon. -at 12:10 pm, professional strength glue, scissors, paint spray, fabric and vinyl adhesive spray in cabinets without lock in unlocked art room. -staff (S2) does not have First Aid certificate. -staff (S5) does not have the required 8 hours of medication training for 2022. The following updated/current documents to be submitted by October 18, 2023: 1. LIC308 Designation of Facility Responsibility 2, LIC500 Personnel Report 3. LIC610E Emergency Disaster Plan (9 pages) 4. Infection Control Plan and Monkeypox Infection Control Plan Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. A $250.00 civil penalty is assessed for repeat violation of section 87309(a) within 12 month period. Failure to submit proof of correction by plan of correction due date may result in additional civil penalty. Deficiencies and plan and proof of corrections were discuss with ED. Due to time constraint, LPA will come back to continue inspection. 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.