Landmark Villa

On this day, March 19, 2026, at 11:20 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced in response to the Unusual Incident Report (UIR) submitted by the facility on March 2, 2026. LPA met with Geraldine Tayo, interim administrator (IADM), and informed the reason for visit. UIR indicated that on February 28, 2026, at around 2:35 pm, resident (R1) was found on the floor in his living room by care staff during safety check. R1 presented with confusion and bruises on the back and face. R1 was sent out and came back the same day. R1 was diagnosed with a transverse process fracture on lower back which will heal on his own time. LPA reviewed R1's file and obtained copies of including but not limited to LIC602A Physician's Reports before and after fall incident; Notification of Hospice Initiation; Death Report; Appraisal; LIC625 Appraisal/Needs and Services Plan; hospital After Visit Summary LPA conducted interview. IADM stated R1 was placed on hospice care on March 4, 2026 and passed away after few days. Death Report showed R1 passed away on March 7, 2026. No deficiency cited. Exit interview conducted and copy of this report provided.

On 02/10/2026 at 9:35 AM, Licensing Program Analyst (LPA) J. Clancy-Czuleger conducted an unannounced Case Management Health and Safety check. LPA met with Administrator, Geraldine Tayo and explained the purpose of the visit. During the health and safety check, LPA observed a total of nine (9) Staff throughout the facility. Residents were gathered in the front common areas preparing for the social activity of Bingo. LPA conducted a tour of the facility, including but not limited to residents' bedrooms, bathrooms, common areas, kitchen, and outdoor areas. LPA observed that the kitchen was clean and the food supply was sufficient. Refrigerator temperature was observed at 33 degrees Fahrenheit and the walk-in freezer at negative 10 degrees Fahrenheit. Clients in care appear to be safe and there are no imminent health/safety concerns on today's date. LPA checked four resident files and four staff files, and 4 of 4 were fingerprint cleared and associated to the facility. No deficiencies cited during the health and safety check. Exit interview conducted and a copy of this report provided.

During investigation of complaint (Control # 15-AS-20190926095603) and upon review of resident's (R1) file and review of facility file at Community Care Licensing (CCL) office, Licensing Program Analyst (LPA) Delmundo learned that resident (R1) who has dementia does not have medical assessments for 2018 and 2019. Facility does not have Dementia Care Plan nor have submitted this plan to CCL. These were discussed with Diane Pederson during one of visits when LPA was conducting investigation. Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due dates may result in civil penalty. Deficiencies and plan and proof of corrections were discussed with Diane Pederson. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.

At 2:00 p.m. on this day, January 13, 2026, a virtual meeting was called. The meeting was attended by the following: Licensing Program Manager Jeremy Fong Licensing Program Analyst Alicia Delmundo Licensee/Corporate Officer Prema Thekkek Executive Director Diane Pederson The following were discussed: 1. Subletting of Lease Agreement - shall be withdrawn within 24 hours and submit proof by January 14, 2026. 2. Non-transferability of license (Title 22 section 87109). 3. Letter dated January 1, 2026 sent to the residents and residents' families to be rescinded and proof to be provided to LPA by January 20, 2026. 4. Outstanding annual fee due and late fee charge - Prema Thekkek indicated she is going to pay on this day. Proof to be submitted by tomorrow, January 14, 2026. 5. Process in having the prospective buyer of the property being brought in as management company and abbreviated application and documents to be submitted to Sacramento. Fingerprint clearance and association requirements for the 2 individuals who are/will be in the facility while application is in the process. A copy of this report provided via email to Prema Thekkek and Diane Pederson.

While at the facility for other reason, Licensing Program Analyst (LPA) Delmundo discussed with Executive Director (ED) Diane Pederson the copy of notification to the residents and residents family members dated January 1, 2026 pertaining to change of ownership. The copy was received by LPA on January 2, 2026. LPA discussed the process with the ED and refer the ED to Title 22 Regulations 87109 and Health and Safety Code 1569.191. LPA also discussed the submission of application for new license. LPA requested ED to have LPA updated. Exit interview conducted and copy of this report provided.

On 09/22/21 at 11:15 AM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an infection control annual inspection and explained the purpose of the visit with administrator. Facility is a three story building with 97 apartments with in room showers/toilets and kitchen. LPA observed 16 staff wearing face masks during visit with 14 residents eating lunch (2 per table) in the first floor dining room. LPA observed screening station located near the front entrance with visitor's log, COVD-19 questionnaire, hand sanitizer, gloves, face masks and no touch temperature probe. Routine symptom screening (+/-) temperature and symptom checks are done at entry for all staff, residents and visitors. Facility has a completed mitigation plan in place dated 04/12/2021 to mitigate the spread of COVID-19. LPA discussed the completed mitigation plan (LIC 808) with administrator as well as COVID-19 infection control practices. Common toilets (male and female) were observed on each floor with adequate supply of paper towels and soap. LPA inspected the facility inside and outside. LPA observed COVID-19 signages posted in common areas to promote hand washing, cough/sneeze etiquette and physical distancing. Facility documents daily temperatures and COVID-19 symptom checks for staff and residents. Pathways were observed to be free of obstruction and fire hazards. Facility has a visitation area next to the dining room. Dining room had tables spaced six feet apart for social distancing among residents. Continued on next page LIC 809-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 A written Emergency/Disaster plan dated 05/13/2021 was posted near the front desk. Centrally stored medications were locked in the medication room. Sharp objects were also locked in the medication room. Toxic chemicals were locked in the housekeeping storage room. Adequate supply of PPE was observed stored in the second floor storage closet. Facility has conducted staff training on infection prevention, symptoms, transmission and proper donning & doffing of PPE. Trash bins with lid operated foot pedal was observed in the first floor employees' toilet room. Infection control designated leader is the administrator. 95 percent of staff and residents have been fully vaccinated since February 2021. There was at least 7 days of nonperishable and 2 days of perishable foods. Emergency food supplies were observed stored in the kitchen and basement. Facility room temperature was maintained at 73 degrees Fahrenheit. A certified administrator is on site a minimum of 20 hours a week to oversee proper business operation and compliance with COVID-19 infection control practices. Fire extinguisher was observed fully charged. Smoke and Carbon monoxide detectors were operational. Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 09/23/2021: · LIC500- Personnel Report · LIC308- Designation of Facility Responsibility · LIC610E- Emergency/Disaster Plan · Evidence of Liability Insurance No deficiencies cited during this visit. Exit interview conducted and a copy of this report provided to administrator.

On this day, September 11, 2025, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with Executive Director (ED) Diane Pederson, and informed the reason for visit. LPA toured the facility inside out with ED. Facility is a 3 story building. LPA inspected the common areas, library, kitchen, dining room, yard, common bathroom and laundry room on the second floor. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Freezers and refrigerators temperatures are checked by kitchen staff and recorded daily, and records showed temperatures were within Regulations range. LPA randomly selected 8 residents apartments for inspection - 2 on the first floor, 3 on the second floor and 3 on the third floor. Hot water temperature in one of the resident's apartments was tested and measured at 110.6 degrees Fahrenheit. The 2 in 1 carbon monoxide and smoke detectors in another resident's apartment was tested and observed in working condition . Facility has evacuation chairs on stairwells . Facility conducts disaster drills at least every quarter, and records showed last conducted August 16, 2025 LPA reviewed 5 staff and 5 resident's files, and interviewed 4 residents. Medications checked, and compared with doctor's orders and LIC622 Centrally Stored Medication and Destruction Record. Facility does not handle resident's cash resources/P&I. .....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 received the following updated/current documents on this same day: 1. LIC308 Designation of Facility Responsibility 2. LIC500 Personnel Report 3. LIC610E Emergency Disaster Plan (9 pages) 4. $3M Liability Insurance certificate No deficiency cited during today inspection. Exit interview conducted, and copy of this report provided.

On this day, May 14, 2025, at 11:35 am, Licensing Program Analyst arrived unannounced to continue the case management visit that was started on January 23, 2025 to obtain additional information. LPA met with Executive Director (ED) Diane Pederson, and informed the purpose of visit. LPA conducted interviews. No deficiency cited. Exit interview conducted and copy of this report provided.

At 12:30 pm on this day, 1/23/25, Licensing Program Analyst (LPA) Delmundo arrived unannounced in response to the Unusual Incident Report (UIR) submitted by the facility on 1/20/25. LPA met with Executive Director (ED) Diane Pederson, and informed the reason for visit. LPA also met with Resident Care Director Geraldine Tayo. UIR indicated that on 1/19/25 at approximately 5:00 am, staff (S2) stated she witnessed the caregiver (S1) physically and verbally handling resident (R1) roughly. S1 was removed from schedule and the ED notified R1's daughter, Ombudsman and Community Care Licensing. Investigation was conducted and S1 was terminated. LPA reviewed R1's file and conducted interviews. LPA obtained copies of resident roster, staff schedule, facility staff's statements, and including but not limited to the following R1's documents: LIC601 Identification and Emergency Contact Information; LIC602A Physician's Report; Appraisal and Re-appraisal No deficiency cited on this day. Exit interview conducted and copy of this report provided.

On this day, September 5, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with Executive Director (ED) Diane Pederson, and informed the reason for visit. LPA also met with Resident Services Director Geraldine Tayo. ED submitted an updated Infection Control Plan on September 28, 2023. LPA toured the facility inside out with ED. Facility is a 3 story building. LPA inspected the common areas, activity room, library, kitchen, dining room. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Freezers and refrigerators temperatures are checked by kitchen staff and recorded daily. Medication room was observed attended by staff. LPA randomly selected 12 residents apartments for inspection - 4 on the first floor, 4 on the second floor and 4 on the third floor. Hot water temperature in one of the common bathrooms was tested and measured at 113.6 degrees Fahrenheit. Facility has carbon monoxide and smoke detectors that were observed in working condition. Fire extinguisher in the kitchen checked, observed fully charge with tag showed serviced January 11, 2024. Facility has evacuation chairs on stairwells . Facility conducts disaster drills at least every quarter, and records showed last conducted June 11, 2024. LPA reviewed 5 staff and 5 resident's files. Medications checked, and compared with doctor's orders and LIC622 Centrally Stored Medication and Destruction Record. Facility does not handle resident's cash resources/P&I. .....continued on n809C 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 2 LPA received the following updated/current documents on this same day: 1. LIC308 Designation of Facility Responsibility 2. LIC500 Personnel Report 3. LIC610E Emergency Disaster Plan (9 pages) 4. $3M Liability Insurance certificate No deficiency cited during today inspection. Exit interview conducted, and copy of this report provided.

Page 2 LPA conducted inspection with ED on 2/07/22. LPA interviewed the following: staff (ED, S1, S2, S4, S5, S6) on 2/07/22, 9/28/23, 9/05/24, 9/13/24 and 4/30/25; R1’s family member (FM1) on 9/13/24; residents (R2, R3, R4, R6, R7, R8) on 2/07/22, 9/28/23 and 4/30/25. LPA tried to reach staff (S3) and home health nurse (HH1), but they did not return LPA’s calls. Allegation: Resident (R1) sustained pressure injuries while in care. S1 stated she does not remember if R1 had pressure injury but thinks R1 had some redness which is usual when one is staying long on the chair and R1 was attended by home health. S2 stated she was not assigned to R1 but observed caregivers attended to R1. S4 stated she does not remember R1 because residents come and go but if she observes skin issue, she reports to the med-tech and she repositions resident every 2 hours. S5 and S6 stated R1 had pressure injury. S6 also stated that that was also the reason R1 was visited by home health which was also stated by FM1. S5 and S6 stated R1 was a difficult resident. S5 further stated when R1 was repositioned, R1 returned to her original position. R1 was provided wedge; however, R1 asked the staff remove it. Review of home health records showed R1 was certified and re-certified for home health care from 2021 to 2022 and at some point, during these periods, R1 was visited by home health due to pressure injury. On 3/08/22 document indicated R1 was discharged from Home Health. It was noted on the document that R1 has no unhealed or stage 2 or higher pressure injury and had no stasis ulcer. Based on interviews and records review, and LPA unable to obtain information from R1, S3 and HH1, the allegation is unsubstantiated. Allegation: Resident's diapering needs are not being met. It was reported that when HH1 asked R1 to stand up so HH1 can see R1’s buttock wound, R1 said, “Let me first pee in my diaper” and when R1 was done, HH1 helped remove the diaper and amount of urine was weighing 2-3x of urine episode and that was causing the stage 2 pressure injury in the buttock. ..............................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 FM1 stated once or twice R1 called her and told her she was not changed but FM1 said it was something she was not aware of. Although FM1 stated that she run a couple of times when she visited and saw used diaper in a plastic bag in R1's bed, she never observed R1 soaked in urine nor not changed. S1 stated when R1 does not come down to the dining room, S1 goes to R1's room to give R1 medications and S1 observed caregiver changing R1's diaper. There were times when R1 will call for assistance and S1 hears the front desk calling for caregiver to attend to R1. S2 stated she never visually observed R1 soaked in urine or soiled and not being attended. S2 also stated she saw caregivers come and go to R1's room to attend to R1. S4 stated she changes residents’ diapers 3x during her shift and as needed. S5 stated residents who need assistance in changing diaper are changed regularly and as needed. S6 stated she changed residents' diapers every 2 to 3 hours and more often if resident is a frequent wetter. S6 further stated that R1 was a frequent wetter and a lot of time, R1 refused to be changed. Six of the residents interviewed stated the staff assist them when they need help. One of this 6 residents has been living in the facility for 8 years and stated that she needs assistance in changing diaper and staff change her 4 to 5 times and as needed. This resident further stated she never had rashes, UTI and/or pressure injury. Based on information gathered, and LPA unable to obtain information from HH1, S3 and R1, the allegation is unsubstantiated. Allegation: Resident's hygiene needs are not being met. It was reported that HH1 observed feces between R1’s buttock and some part at R1’s back which showed that the feces had been sitting there and that when staff wiped off, R1 was not cleaned entirely . .......continued on 9099C (page 4) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Page 4 FM1 stated R1 complained about the water being cold and would not want to take a bath, but FM1 tested the water and the temperature was okay. FM1 also stated that when FM1 started coming to the facility, R1 started taking a bath. All 6 residents interviewed stated the staff assist them when they need help. When LPA conducted inspection during the 10-day visit, when LPA and the ED entered one of the residents’ apartment, LPA observed a caregiver present and assisting the resident in that apartment. Based on information gathered, and LPA unable to obtain information from HH1, S3 and R1, the allegation is unsubstantiated. Allegation: Staff does not assist resident when requested. All 6 residents interviewed stated the staff assist them when they need help. When LPA conducted inspection during the 10-day visit, when LPA and the ED entered one of the residents’ apartment, LPA observed a caregiver present and assisting the resident in that apartment. Based on information gathered, and LPA unable to obtain information from HH1 and R1, the allegation is unsubstantiated. Allegation: Staff does not treat resident with dignity and respect. It was reported that HH1 observed the staff being disrespectful to R1. All staff interviewed denied being abusive to any residents. They stated they never observed other staff not treating residents with dignity and respect. ..............continued on 9099C (page 5) 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 5 FM1 stated she never heard any staff being disrespectful to R1 or other residents. All 6 residents interviewed stated staff were never abusive to them and other residents. LPA reviewed Home Health records and documentation and didn’t observe any notes indicating HH1 observed abuse by facility staff. Based on information gathered, and LPA unable to obtain information from HH1, S3 and R1, the allegation is unsubstantiated. Based on interviews, observations and records review, there’s not a preponderance of evidence standard to prove that violations occurred, therefore, the 5 allegations are closed as unsubstantiated. Exit interview conducted and copy of this report provided.

On 02/02/2026 at 3:15PM, Licensing Program Analyst (LPA) Carol Fowler arrived unannounced to conduct a case management visit. LPA met with Administrator, Geraldine Tayo. While LPA Carol Fowler was at the facility for a complaint investigation (#15-AS-20260130110921), the following deficiencies were observed. During the complaint investigation, LPA observed that the facility didn't have an adequate supply of hygiene supplies. While LPA was conducting a record review and the Administrator informed LPA that the former staff file was missing from the facility. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties. Exit interview conducted. A copy of this report, and appeal rights provided.

While at the facility to deliver the findings for a complaint #15-AS-20200710153037), Executive Director Diane Pederson informed Licensing Program Analyst (LPA) Delmundo that they have completed the facility's Infection Control Plan that is due for submission this month of June. Copy of the Infection Control Plan provided to LPA on this same day, June 1, 2022. Exit interview conducted and copy of this report provided.

Page 2 Allegation: Resident (R1) sustained multiple falls resulting in injuries. It was alleged that R1 fell on September 2019 outside in the facility garden; the drain cover was not properly covered and R1 tripped, broke her right shoulder, and was left for 2 hours. It was further alleged that R1 fell 4x in April 2020 and May 2020 resulting to broken ankle, toe and fingers. The Department conducted interviews, obtained and reviewed R1’s Physician’s Reports, Appraisal/Needs and Services Plan, medical records, facility notes and incident reports. R1 fell in November 2019 when R1 was walking her dog in the back area. It could not be proven that R1 had tripped over an open drain cover . At that time, R1 had been appraised as being ambulatory without needing assistance . Progress notes indicated that staff immediately heard R1 and responded; R1 was immediately sent ou t to hospital and treated for an arm fracture. Facility reassessed R1 and determined that she needed additional supervision and care. The staff signed off daily for the tasks related to her increased care including additional safety checks. In January 2020, R1 experienced an unwitnessed fall in her room, with no injuries, bruising, or pain noted. The two other falls, with injury, were unwitnessed while R1 was in her room and on April 2020 when R1 attempted to use the bathroom on her own. S taff reported that R1 had been provided with additional room checks and reminders to call for assistance for bathroom transferring; documents obtained indicated staff were provided with this instruction . R1 had two more visits to the emergency department due to staff observing R1 with leg edema. The information is insufficient to establish that R1’s multiple falls were due to neglect or lack of supervision. Allegation: Resident (R1) not provided medical attention in a timely manner. The documents indicated the facility reported each incident and sought immediate medical treatment by having hospital evaluations. A review of R1’s incident reports and staff progress notes showed that facility staff had contacted paramedics and R1’s family to transport R1 to the hospital for an evaluation and treatment of injuries when R1 fell. Facility also sent R1 out to the hospital for treatment of leg edema. S1 reported during interview of personally responding to the fall in November 2019 and contacting 911 immediately after assessing R1, which was corroborated by documents obtained. The information is insufficient to establish that facility staff did not seem timely medical attention for R1. ,,,,,,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 do not respond to resident's pull cord in a timely manner. Pull cord activations are answered by front desk and front desk staff will radio staff to respond to residents’ requests/calls. Seven staff (S1, S2. S3, S4, S5. S6 and S7) were interviewed who stated they are to respond immediately when pull cords are activated, and if unavailable, staff inform the front desk so that other staff can be requested to respond. The facility does not have a system that records when residents activate the pull cord, nor when staff respond. Therefore, it could not be determined whether R1 had called for assistance before attempting to use the shower or toilet, nor when staff responded to the pull cord being activated by R1. Residents (R2, R3 and R4) were interviewed. R2 and R3 stated they seldom use their pull cords and staff usually respond immediately. R4 indicated he does not use pull cord and use his cell phone instead and staff respond immediately. The information was insufficient to determine that the facility staff had failed to respond to a call for assistance in a timely manner. Based on all information obtained by the Department, the 3 allegations, “R1 sustained multiple falls resulting in injuries”, “R1 not provided medical attention in a timely manner”, and “Staff do not respond to resident's pull cord in a timely manner”, are closed as unsubstantiated. An unsubstantiated finding means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit interview conducted and copy of this report provided to Diane Pederson. 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 2 Review of Medication Administration Record (MAR) showed R1 was generally compliant with taking her medications as directed. A review of the medication administration record for R1 indicated that staff had provided medications. S3 and S4 confirmed having signed their initials on the days and times that medication was provided or refused. The record indicated that one medication was occasionally refused by R1. S3 and S5 reported that R1’s physician was informed when the medication was refused. The information is insufficient to determine that the facility staff had failed to properly administer R1’s medications. B ased on all information obtained by the Department, the allegations is unfounded. A finding that a complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview conducted and copy of this report provided to Diane Pederson.

On this day, 6/01/2022, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management visit. LPA met with Executive Director (ED) Diane Pederson and informed the purpose of visit. During the course of investigation for complaint (#15-AS-20200710153037), the following deficiencies were observed: Facility staff did not update resident’s (R1) Appraisal/Needs and Services Plan after each change in condition/hospital visit. Executive Director (ED) stated that the facility updated R1’s care plan after R1’s first fall on 11/16/2019. Staff continued to use the same updated care plan moving forward, only adjusting the need for increased safety checks and providing constant reminders to R1 to utilize her pull cord. R1’s records revealed only two (2) Appraisal/Needs and Services Plan on file dated 9/23/2019 and 11/18/2019. It was also noted that during interview of R1’s family member (FM1) that R1 ran out of one of the medications. Facility’s records indicated they had contacted FM1 on December 2019 to pick up the medication from the pharmacy and that FM1 picked up the said medication and delivered to facility on 12/6/2019. However, when LPA requested for copies of LIC622 Centrally Stored Medication and Destruction Records on July 23, 2021 for further review, ED stated the facility no longer have the documents. On 2/07/2022, LPA verified and ED confirmed they no longer have the records. D eficiencies are cited from Title 22 California Code of Regulations on 809D. Failure to correct deficiencies and any repeat violations within 12 month period may result in civil penalties. Exit interview conducted. A copy of this report, Appeal Rights and LIC9098 Proof of Correction form provided.

Licensing Program Analyst (LPA) Delmundo conducted a health and safety inspection as a result of the Department receiving a complaint (Control # 15-AS-20220203093410). LPA met with Executive Director (ED) Diane Pederson and informed the purpose of visit. LPA conducted inspection with ED. LPA inspected the common area, lobby. dining area, kitchen, side patio, and selected 5 apartments for inspection. Hallways and passageways were observed free of obstructions. LPA observed the following: 1. Hand washing poster in each of the five apartments but not in the kitchenettes. 2. No trash bin with pedal operated lid outside the isolation room. No deficiency cited during this visit. Exit interview conducted and copy of this report provided.