Brethren Hillcrest Homes.

Regarding allegation: Staff left resident in the sun for an extended period of time causing sunburns . It is alleged that R1 was left outdoors for a long period from morning to late evening. Staff did not ensure R1’s safety which caused R1 to get sunburn on her body. The investigation reveals the following: Residents interviews reveal that ten (10) out of ten (10) residents denied the allegation above. Staff interviews reveal that seven (7) out of seven (7) staff denied the allegations above. Residents responded that residents prefer to remain indoors, and residents are not aware of other residents being left outside for long period of time. Residents’ interviews reveal that residents who are observed to be outside are monitored by staff. S2 stated that staff provide hats, sunscreens, or move residents to shaded areas to prevent sunburn. S4 stated that R1’s has not been observed with any skin bruises, rashes, or tears during morning or evening shifts that would indicate any sun damage. Record review revealed that recent hospital visit on 10/02/2025 did not change any current medications or indicate any new prescription for any skin damage. Based upon investigation, client and staff interviews, and LPA observations, there was no evidence that R1 has been left out exposed in the sun for long period of time that may have caused sunburn. Regarding allegation: Staff handle resident roughly when assisting with oral care. It is alleged that staff has hurt R1 by forcefully removing dentures. The investigation reveals the following: Residents interviews reveal that nine (9) out of ten (10) residents denied the allegation above. Residents stated that staff were considerate of their needs when helping with activities of daily livings (ADLs) such as transferring, toileting, or showering. Residents stated that staff were not rough when assisting residents with removing devices such as dentures. Staff interviews revealed that seven (7) out of seven (7) staff denied above allegation. S1 or S2 denied knowing any staff being rough when assisting residents with prosthetic devices. R1 interview reveals that R1 feels pain in the gums because R1 has been losing teeth. R1 did not express that staff were causing pain. S4 stated that dental appointment had been made but dental appointments were cancelled twice to assist R1 with other medical needs. Based upon the investigation, client and staff interviews, and LPA observations, staff did not handle resident rough when assisting with oral care and staff is assisting with dental appointments to meet R1’s dental needs. Report continues on page LIC-9099C... 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 Regarding allegation: Staff take residents blankets away. It is alleged that staff forcefully removed R1’s blanket while R1 was sleeping. The investigation reveals the following: Residents interviews reveal that nine (9) out of ten (10) residents denied the allegation above. Residents stated that staff were considerate of their needs when helping with activities of daily living (ADLs) such as transferring, toileting, or showering. Residents stated that staff treat them respectfully and are not rude to residents. Three residents stated that there is no other place the residents would like to be. Residents stated that none had experienced staff pulling their blanket or pillows away from them. Staff interviews revealed that seven (7) out of seven (7) staff denied above allegation. S1 and S2 stated that community policy allows staff anonymous reporting. S1 stated that community administration does not tolerate staff mistreating residents and an investigation would be initiated. S1 stated that staff would be transferred to other duties during investigation. S1 stated that there has been no recent staff report of staff mistreating any residents. Based upon the investigation, client and staff interviews, and LPA observations, there is no evidence to show that staff are handling residents in an unprofessional manner by pulling residents blanket away. Regarding allegation: Resident fell and staff did not address the residents injury. It is alleged that R1 fell causing a left bruise on her ankle and staff did not ensure R1 received proper care for injury. The investigation reveals the following: On discharge hospital documents dated 10/02/2025, R1 was taken to hospital to get X-ray and there was no ankle injury found. S2 and S4 identified hospital visit on 10/02/2025 as a result of R1’s fall. Interview with S2 indicates that R1 participates in a care plan where a nurse practitioner visits R1 twice a week and a doctor visit once a month for residents who are not easily able to attend appointments. S2 and S4 stated that R1 complains of pain whenever someone touches her. S2 and S4 denied refusing to provide medical assistance to R1 for her pain. The Community has licensed nurses on site and S1 stated that it is community policy to have nurse attend residents who have fallen. An assessment is made, and licensed nurse may decide to transport resident to hospital. The community will call the party responsible and doctors who may decide to transport residents to hospital even if license nurse assessment did not recommend transport to hospital. Residents’ interviews reveal that ten (10) out of ten (10) residents denied the allegation above. Report continues on page LIC-9099C... 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 resident (R10) described two incidents where resident fell and nurse immediately responded and stayed with resident until paramedics arrived. Ten (10) out of ten (10) residents stated that staff is responsive to residents medical needs. Staff interviews reveal that seven (7) out of seven (7) staff denied the allegations above. Staff is responsive to residents call for help and provide medical assistance as needed. Staff interview revealed that staff is not aware of any other staff refusing to provide medical assistance to residents. Based upon the investigation, client and staff interviews, document review, and LPA observations, the staff provided medical assistance to residents and has an operating plan to handle residents falls. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview was held with Director Keith Kasin. A copy of the report was provided.

Licensing Program Analyst (LPA) Kimberly Ramirez and LPA Gabby Castro conducted subsequent annual inspection on 8/05/2025. LPAs identified themselves and met with Administrator Keith Kasin and discussed the purpose of today’s visit. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: This facility is licensed to serve fourteen (14) ambulatory residents and five hundred sixty (560) non-ambulatory residents over the age of 60. This facility may retain no more than fifteen (15) hospice residents. There are eight (8) residents under hospice care at this time. This facility provides care to assisted living residents in 4 different wings of the facility. Pinecrest census – seventeen (17), Cedar Court census – ten (10), Maple Court/Birch Court census – forty-nine (49), and twenty-four (24) in Southwood Lodge Memory Care. The Southwoods Lodge Memory Care is approved for delay egress. The total census for this facility is two hundred seventy-seven (277) as of 08/5/2025. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: See 809-C for continuation. 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 Infection Control: Staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed required annual training, CPR and First Aid for eight (8) out of the eight (8) personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for eight (8) out of the eight (8) personnel records reviewed. Staffing: Administrator Certificate for Keith Kasin (70005649740) expires 08/10/2026. Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication rooms and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MAR) electronic log to document medications given. The facility provides incidental medical services. Resident Records/Incident Reports: LPA Ramirez reviewed Resident files for eight (8) residents. Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed. No deficiencies were observed during this inspection. Exit interview was conducted. A copy of this report was provided.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted a unannounced required annual inspection on 08/01/2025 . LPA Ramirez identified herself and met with CEO-Matthew Neeley and discussed the purpose of today’s visit. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: This facility is licensed to serve fourteen (14) ambulatory residents and five hundred sixty (560) non-ambulatory residents over the age of 60. This facility may retain no more than fifteen (15) hospice residents. There are eight (8) residents under hospice care at this time. This facility provides care to assisted living residents in 4 different wings of the facility. Pinecrest census – seventeen (17), Cedar Court census – ten (10), Maple Court/Birch Court census – forty-nine (49), and twenty-four (24) in Southwood Lodge Memory Care. The Southwood Lodge Memory Care is approved for delay egress. The total census for this facility is two hundred seventy seventy (277) as of 08/1/2025. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: See 809-C for continuation. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected four (4) resident rooms. All resident bedrooms contained the required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. Facility maintains a monthly waterlog to record water temperature throughout the facility. LPA Ramirez observed postings encouraging proper hand washing etiquette in restrooms. LPA Ramirez observed grab bars near toilets and inside showers. LPA Ramirez observed evacuation chairs in stairways. Food Service: LPA Ramirez observed sufficient supply of non-perishable for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0 degree F (-17.7 degree C), and refrigerators with a maximum temperature of 40-degree F. (4 degree C). LPA Ramirez observed facility weekly and daily menu. LPA Ramirez observed kitchen staff performing a deep cleaning of the kitchen area. LPA Ramirez observed several dining room servers disinfecting tables and counters while wearing gloves and hair nets. Planned Activities: LPA Ramirez observed several residents participating in a staff-led seated exercise. LPA Ramirez observed a calendar for August of 2025 with various activities and outings for residents. LPA Ramirez observed sufficient outdoor space in both assisted living section and in memory care. Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed internet access and a facility land line. SEE 809-C for continued report. 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 Residents with Special Needs: Facility pool was observed to be inaccessible to residents with physical and mental disabilities. LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. LPA Ramirez observed several oxygen tanks in resident rooms secured in stands. Knives, sharps, or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Auditory devices and delay egress perimeters were observed to be in working order. Due to time constraints, LPA Ramirez will return later to complete annual inspection. No deficiencies were cited at this time. Exit interview was conducted with Matthew Neeley. A copy of this report was provided.

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced collateral visit at the facility to conduct interviews regarding a recent incident at a different licensed facility. LPA met with Desiree Eudave Director of Resident Care and explained the reason for the visit. The purpose of this visit was to conduct interviews with 1 resident regarding the incident that occurred at the residents' previous facility. Exit interview was conducted with Desiree Eudave and a copy of this report was provided.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted subsequent annual inspection on 7/13/2024. LPA met with Lynn Palin (Director of Social Work) and discussed the purpose of today’s visit. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Operational Requirements: This facility is licensed to serve fourteen (14) ambulatory residents and five hundred sixty (560) non-ambulatory residents over the age of 60. This facility may retain no more than fifteen (15) hospice residents. There are six (6) residents under hospice care. This facility provides care to assisted living residents in 4 different wings of the facility. Pinecrest census – four (4), Cedar Court census – eleven (11), Maple Court/Birch Court census – thirty-four (34), and twenty-two (22) in Southwoods Lodge Memory Care. Southwoods Lodge Memory Care is approved for delay egress. Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed required annual training, CPR and First Aid for six (6) out of the nine (9) personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for nine (9) out of the nine (9) personnel records reviewed. Staffing: Administrator Certificate for Keith Kasin (70005649740) expires 08/10/2024 and is in the process of being renewed. Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication rooms and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MAR) electronic log to document medications given. The facility provides incidental medical services. See 809-C for continuation. 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 Resident Records/Incident Reports: LPA Ramirez reviewed Resident files for nine (9) residents. Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed. No deficiencies were observed during this inspection. Exit interview was conducted. A copy of this report was provided.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted required annual inspection. LPA met with Lynn Palin (Director of Social Work) and discussed the purpose of today’s visit. Dan Townsend (Director of Facility Operations) arrived shortly after to assist with tour. This facility is licensed to serve fourteen (14) ambulatory residents and five hundred sixty (560) non-ambulatory residents over the age of 60. This facility may retain no more than fifteen (15) hospice residents. There are six (6 ) resid ents under hospice care. This facility provides care to assisted living residents in 4 different wings of the facility. Pinecrest census – four (4), Cedar Court census – eleven (11), Maple Court/Birch Court census – thirty-four (34), and twenty-two (22) in Southwoods Lodge Memory Care. Southwoods Lodge Memory Care is approved for delay egress. Total census for this facility is seventy-one (71). LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected ten (10) rooms; of which three (3) in Southwoods Lodge Memory Care and seven (7) random rooms in assisted living wing of the facility. All resident bedrooms contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. Facility maintains a monthly waterlog to record water temperature throughout the facility. LPA Ramirez observe postings encouraging proper hand washing etiquette in restrooms. LPA Ramirez observed grab bars near toilets and inside showers. LPA Ramirez tested emergency pull cord in room#209. Staff responded 3 minutes later to assist. LPA Ramirez observed evacuation chairs in stairways. See 809-C for continuation. 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 Food Service: LPA Ramirez observed sufficient supply of non-perishable for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0 degree F (-17.7 degree C), and refrigerators with maximum temperature of 40 degree F. (4 degree C). LPA Ramirez observed facility weekly and daily menu. LPA Ramirez observed kitchen staff preparing for lunch while wearing hair nets and gloves. LPA Ramirez observed several dining room servers disinfecting tables and counters while wearing gloves and hair nets. Planned Activities: LPA Ramirez observed several residents participating in a staff led seated exercise. LPA Ramirez observed a calendar for June of 2024 with various activities and outings for residents. LPA Ramirez observed sufficient outdoor space in both assisted living section and in memory care. Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed internet access and a facility land line. Residents with Special Needs: Facility pool was observed to be inaccessible to residents with physical and mental disabilities. LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. LPA Ramirez observed several oxygen tanks in resident rooms secured in stands. Knives, sharps, or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Auditory devices and delay egress perimeters were observed to be in working order. Due to time constraints, LPA Ramirez will return later to complete annual inspection. No deficiencies were cited at this time. Exit interview was conducted with Lynn Palin (Director of Social Work). A copy of this report was provided.

Interviews conducted with residents revealed, 7 out of 7 residents interviewed stated their appliances, including refrigerator have been in working condition. 1 out of the 7 residents mentioned that the refrigerator currently in the apartment had been placed within the last 4 days and was not able to provide further information due to cognitive skills. Per residents, staff respond quickly to residents’ work order reports. The turnaround to fixing something is no later than the same day, including weekends. Interviews with staff revealed, 7 out of 7 staff interviewed stated facility has a security staff on duty 24 hours every day to which the reports can be made, and who will route or provide the services accordingly on the weekends. Other than that, there is a work order line to which residents report any work order services. Per Director of Facility Operation on 10/14/23, he received a call around 5:00pm reporting a refrigerator was not working. At 5:45pm the staff arrived at the facility and replaced the refrigerator with a temporary refrigerator, as a permanent refrigerator attempted to be place in the room did not fit through the door. An order for a fitting refrigerator has been placed and will be put in the resident’s room once it arrives. Per staff, appliances are kept in the facility’s storage room which allows the facility to provide appliances upon a resident reporting an appliance is out of order. Staff also stated that staff are on call when not available at the facility after working hours. Interview with housekeeper serving Resident #1’s room did not observe any issues with the refrigerator within the last three weeks. Interview with Operations Coordinator who receives all the work orders, stated there have not been any work orders received prior to 10/14/23 for a refrigerator being out of order. LPA observed 9 refrigerators/freezers in the residents’ rooms, each seem in working order. Although the allegations may have occurred, the facility responded within two hours to the report of the refrigerator not working and provided a working refrigerator within a window of 2 hours. Although maintenance manager was not scheduled on Saturday, a technician was on schedule until 4:00pm. After hours the manager and director were on call and responded to the call and provided assistance within 45 minutes. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Desiree Eudave and a copy of this report was provided.

Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. Staff#2, social worker and Keith Kasin, administrator. LPA explained the reason for the visit. The facility is licensed to serve fourteen (14) ambulatory residents and 560 non-ambulatory. Facility cares for elderly residents and had approved six (6) hospice residents. Annual licensing fees are current. During the visit, LPA conducted staff/resident interviews, used CARE inspection tool, toured the facility, reviewed food supply, reviewed medications and records, and reviewed staff/residents’ records. The facility is a large campus that includes independent living, assisted living, memory care and skilled nursing. LPA and staff#2 toured the assisted living and memory care buildings. Assisted living buildings are Maple Court, Birch Court, and Cedar Court. Maple Court building is connected to Birch Court building which is a two story building. The building had resident bedrooms, kitchenette, dining room, activity room, beauty salon, library, and kitchen. Memory care building is Southwoods Lodge which is a single story building. Residents’ rooms are furnished with appropriate furniture for residents’ comfort. The hallways and stairways are clear and free of any obstructions. The required evacuation chairs are located at the second-floor stairways. Bathrooms are furnished with grab bars and nonskid surfaces. (-continued in 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 Common areas are observed for the ability to safely serve the needs of the residents. Hot water temperature is in a range of 113.5 to 114.4 degrees Fahrenheit which is within Title 22 Regulation guidelines. Sufficient of linen supplies and personal hygiene supplies are observed. Medications are centrally stored, locked and inaccessible to residents in care. Elevators are operating at the time of the visit. Cedar Court is a separate building across from Maple Court and Birch Court. Resident rooms were observed to have all the required items. Memory care, Southwoods is located across from Cedar Court. The memory care unit requires a code to enter. The building was toured and was observed to contain all required items. Sufficient supply of perishable and non-perishable foods was observed. Refrigerators, freezers, microwaves, ovens, and counter tops observed to be clean. Plates, cups, glasses and utensils are sufficient for the current census. A comfortable temperature of 73 degrees Fahrenheit maintained throughout the entire facility. Smoke detectors and carbon monoxide detectors are operational. Fire extinguishers are located throughout each building and the last service is 12/2/22. The grounds are properly maintained and there were no hazards observed. No bodies of water observed. Residents/ staff records were reviewed and current. Medications are documented properly and given as prescribed. Per California Code of Regulations, Title 22, there were no deficiencies observed during the visit. Exit interview held with administrator. A copy of the report was provided.