Vista del Mar Senior Living.

On May 26, 2026, at 1:30 pm, an office meeting was held to discuss Complaint 11-AS-20240429113918. Present at the meeting were Eva Alvarez, Licensing Program Manager (LPM); Antonine Richard, Licensing Program Analyst (PLA); Suzette Johnson, Executive Director (ED), People Operations; Claudia Crowley; and James Bender, Vice President. During the meeting, LPM reviewed the details of the Complaint. On May 16, 2025, the Department substantiated an allegation that a resident sustained a fracture due to lack of care from staff. At this time, the Department is considering an enhanced civil penalty under Health and Safety Code Section 1569.49(f). The department is reviewing the complaint to determine whether to assess an enhanced civil penalty for Serious Bodily Injury pursuant to H&S 1569.49(f). The total civil penalty for Serious Bodily Injury is $10,000. An exit interview was conducted with Suzette Johnson, Executive Director, and a copy of this report was provided.

Record reviews have indicated that S1 has fulfilled all staff requirements under personnel requirements and personnel records and is eligible to work at and are associated to the facility. Interviews revealed that nine (9) out of ten (10) residents and all six (6) staff have denied the allegation has taken place. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. There have been zero (0) deficiencies cited during today's visit. An exit interview was conducted with Suzette Johnson - Executive Director, and a copy of this report has been provided.

Allegation: Staff gave a resident the wrong medication. It is alleged that facility staff gave a resident in care medication for two days that were prescribed to a different resident in care. On 04/09/26 from 11:00 am- 12pm LPA conducted Interviews with S1-S4 regarding the allegation above. 4 of the 4 staff interviewed denied the above allegation. Per 4 of 4 of the staff interviewed, residents with the same or similar name staff are verifying birth dates prior to administering medications. Additionally, 2 of the 4 staff interviewed reported that the facilities electrical medication administration record (EMAR) has some of the resident’s pictures which are also used to confirm that the medication is being administered to the correct resident. On 04/09/26, 4 of the 4 staff interviewed reported that a supervisor is notified if a medication error occurs. On 04/09/26 from 1pm- 2:30pm LPA conducted interviews with R1-R10 regarding the allegation above. 7 of the 10 residents interviewed denied the allegation above. 1 of the 10 residents interviewed reported managing their own medications therefore they have no knowledge of the allegation above. 2 of the 9 residents interviewed confirmed the allegation above and report they made the staff aware of the error. On 04/22/26 LPA Villegas conducted a review of documents obtained, per preplacement appraisal dated: 07/20/21, Physicians report dated:12/09/25, and Service plan dated: 09/12/25 R1 requires assistance with medication and R1 cannot store nor administer their own medications. On 04/22/26 The Department addressed similar complaint allegation which was found to be unsubstantiated. 05/01/26 LPA Villegas conducted a medication review and observed all medications to be accounted for and documented on EMAR. 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 conducted, and a copy of this report was not provided.

Observations revealed the following: The memory care unit has a spread layout and houses approximately 35 residents, including residents requiring incontinence care and identified as fall risks. Staff reported grouping residents in a common area for visibility. At the time of the visit, approximately 4–5 staff were present. Based on the layout and resident care needs, this level of staffing may limit the ability to provide continuous supervision, particularly during overnight hours. Interviews conducted revealed the following: Staff (S1–S5) reported the fall was unwitnessed and discovered during morning rounds, and staff were unable to determine when or where the fall occurred. Staff (S1) reported four staff were scheduled; however, only three staff were present on the night shift due to staffing changes. Staff (S2–S3) confirmed three staff were assigned to the nocturnal shift. Staff (S6) reported that three staff typically care for approximately 35 memory care residents during night shift and stated this may not be sufficient to meet resident care needs. Witnesses (W1–W5) reported concerns regarding night supervision, staffing levels, and prior unwitnessed falls. Witnesses (W6–W7) reported no concerns. Records review revealed the following: Review of the February 2026 staffing schedule confirmed that three staff, including registry staff, were assigned to the overnight shift on 02/13/2026–02/14/2026. Records confirmed the resident sustained an injury consistent with a fall that occurred overnight. Documentation did not identify the time or circumstances of the fall and did not demonstrate staff awareness at the time of the incident. Nursing notes indicate limited information was available from the overnight shift regarding the incident. Review of incident reports and resident records identified a pattern of unwitnessed falls in February 2026, including incidents on or about 02/06/2026, 02/10/2026, and 02/14/2026, where residents were found on the floor with injuries during morning hours. Documentation consistently indicated staff were unaware of when or how the falls occurred. While appropriate medical care was provided after discovery, records do not demonstrate effective overnight monitoring. Based on the evidence gathered, interviews conducted, observations, and records reviewed, the preponderance of evidence standard has been met. Therefore, the allegation is SUBSTANTIATED. This is a violation of California Code of Regulations, Title 22, Division 6, Chapter 8. A citation is issued on the attached (LIC-9099D). An exit interview was conducted, and a copy of this report and appeal rights were provided to the Administrator.

INVESTIGATION REVEALED THE FOLLOWING: Allegation: Staff handled residents in an aggressive manner. The complaint alleges that staff at a facility handled Resident #1 (R1) aggressively. On February 14, 2026, both (R1) and Resident #2 (R2) attempted to use the restroom at the same time. According to reports, a staff member aggressively grabbed (R1), pulled (R1) out of the restroom, pinched (R1's) arm, and hit (R1's) head. Further investigations revealed no visible markings or bruises on (R1); however, the administrator stated that an internal investigation was conducted, resulting in the termination of the staff member involved. No further information has been provided regarding this situation. On February 23, 2026, between 10:20 AM and 02:10 PM, the Department interviewed residents members identified as Resident #1 through Resident #11 (R1-R11). Ten (10) out of eleven (11) residents could not validate this claim. (R2-R11) were under the care and supervision of Staff #1 (S1) on February 14, 2026. All residents praised the staff for their professionalism and courteous behavior. They confirmed that they had never experienced or witnessed any aggressive mistreatment of residents. (R2-R11) stated that if such in appropriate behavior were observed, it would be reported to management or Community Care Licensing (CCL). During the interview (R1) reported a mistreatment incident involving Staff #1 (S1), claiming that the (S1) roughly grabbed (R1) by the left arm and struck (R1) several times on the head. (R1) stated that (R2) was present during the incident but not in any way involved in the restroom issue. (R1) did not provide the staff’s name or a clear description and claimed to have called 9-1-1 for law enforcement, but they did not arrive. The statement from (R1) disputes the information reported to (CCL). (R1) mentioned that, despite being struck multiple times on the head, no medical attention was deemed necessary, and this was not reported to management. According to (R2), no such incident occurred. (R2) stated that any inappropriate behavior by staff will be reported immediately and clarified that no such incident has ever occurred on February 14, 2026. On February 23, 2026, between 09:30 AM and 12:00 PM, the Department interviewed staff members identified as Staff #2 through Staff #5 (S2-S5). Four (4) out of the four (4) staff members could not corroborate this claim involving (R1) and (S1). All staff members were verified to have acted appropriately, both verbally and physically, towards the residents. (Evaluation Report continues LIC 9099-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 (S3) and (S4), who were working on the day of the incident, did not witness any inappropriate behavior by staff members. However, they received inconsistent accounts of what transpired between (R1) and (S1). (S3) reported to have walked in during the incident involving (R1) and noted that (R1) appeared agitated while getting out of the shower. According to (S3), (S1) left the scene after supervising (R1) out of the shower, and there was no physical engagement with (R1). (S3-S4) examined (R1) and did not observe any injuries or bruises on (R1). Both (S3) and (S4) confirmed that (R2) was present in the room when this incident occurred. Both (S2 and S5) stated that an investigation was conducted. They clarified that S1 is not an employee of Vista Del Mar but rather of Great Comfort Home Care, which the facility uses for staffing. Additionally, (R1) provided inconsistent accounts of what occurred. (S5) further clarified that (S1) was not terminated, as was previously reported. On February 23, 2026, between 02:00 PM and 02:30 PM, the Department interview witness identified as Witness #1 (W1) by telephone. (W1) has information about the incident from (R1) but did not witness it. (W1) also noted that (R1) tends to distort statements unintentionally and may have confabulation issues. The Department made several attempts to contact Staff #1 (S1) for an interview, but the calls went unanswered and were not returned. During the investigation on February 23, 2026, the Department observed staff members interacting with residents and noted that their conduct was appropriate. The Department found that the facility upholds the rights of its residents. Posters detailing Resident Rights, Personal Rights, were displayed prominently throughout the facility. The Department inspected for bodily injuries on (R1) and found none. Furthermore, recent phone records show no log of (R1) making any 9-1-1 calls on February 14, 2026, confirming that there was no emergency. The Department reviewed Resident #1 (R1’s) Medical Assessment for Residential Care Facilities for the Elderly LIC 624A (dated 12/15/25), Face Sheet and Emergency Information (dated 12/29/25), Service Plan (dated 12/31/25), Preplacement Appraisal Information LIC603A (dated 12/30/25) and Unusual Incident Report LIC 624 (dated 02/2025) revealed that (R1’s) medical diagnosis contributes to (R1’s) line of thinking/belief system. Further review of Medication Administration and Physician’s Orders (dated 02/23/26) revealed (R1) is on 19 prescribed medications and (8) of the (19) contribute to risk of unusual bruising and mental status conditions of dizziness and confusion (ref: National Institute of Health). (Evaluation Report continues LIC 9099-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 Based on the information gathered, there is not enough evidence to support the allegation mentioned above. Based on the information gathered from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is Unsubstantiated . An exit interview was conducted with Suzette Johnson, and copies of the reports were provided.

Allegation: Questionable death. It is being alleged that facility staff did not respond or take appropriate action when resident in care requested medical assistance, which resulted in residents death. On 01/20/26 and 01/27/26 LPA conducted interview with S1-S6 regarding the allegation above. 6 of the 6 staff interviewed denied the allegation above and reported staff do not refuse to call 911 when needed. Additionally, 6 of 6 staff reported that a nurse or med tech will conduct an assessment when a resident is feeling unwell. On 01/27/26 from 11am-12:30pm LPA conducted interviews with R2-R11 regarding the allegation above. 6 of the 10 residents interviewed denied the allegation above and reported that facility staff assist them when assistance is requested. 1 of 10 residents interviewed confirmed the allegation above and reported that staff does not provided assistance when needed. 3 of 10 residents interviewed reported they have not had the need to ask for assistance but state they believe the staff would provide assistance. On 01/27/26 LPA conducted a review of R1's file. LPA observed that the physicians report dated: 09/18/25 indicates that R1's primary diagnosis were: acute and chronic respiratory failure with hypoxia, COPD, diabetes mellitus type 2, hypertensive heart disease with heart failure,dysphagia, muscle weakness, morbid obesity due to excess calories, difficulty walking, incentive spirometry, CPAP, and oxygen via nasal canula. On 01/27/26 LPA conducted a review of physicians attestation form dated: 01/14/26. Per attestation form the immediate cause of death was a cardiac arrest. Allegation: Staff did not seek medical attention for resident. It is being alleged that facility policy prohibits caregivers from calling 911 directly. On 01/20/26 and 01/27/26 LPA conducted interview with S1-S6 regarding the allegation above. 6 of 6 staff denied the allegation above and reported that caregivers are allowed to call 911 in an emergency situation and to not wait until they find a med tech or nurse to call 911. Additionally, 4 of 6 staff interviewed reported that a meeting was held where caregivers were told that they are allowed to call 911 when needed. On 01/27/26 from 11am-12:30pm LPA conducted interviews with R2-R11 regarding the allegation above. 6 of 10 residents interviewed denied the allegation above and reported that staff have not refused to call 911 when needed. 4 of the 10 residents interviewed reported they have not needed 911 to be called but believe staff would call 911 if needed. 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 conducted, and a copy of this report was provided.

Regarding the Allegation : Staff do not ensure the residents shower is properly working. This complaint alleged that the facility did not provide a working shower for residents’ needs. LPA Calderon inspected room 120 and noted the shower head dripping but working. LPA Calderon inspected rooms 125, 132, 134 and room 206. All showers were working. Records review indicate the following: Work order (dated 12/26/2025) to fix shower head in room 120 was ordered. Interviews indicate the following: S2 indicates that resident in room 120 the shower head was dripping, and a new part was ordered. S2 states that the shower works. 5 out of 5 staff deny the allegation. R1 was not in room for interview. 23 out of 24 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff do not ensure the residents shower is properly working” is found to be UNSUBSTANTIATED. Regarding the Allegation : Staff do not ensure the facility is free of cockroaches. This complaint alleged that the facility did not provide a free environment with no cockroaches. LPA Calderon inspected room 120 and found no cockroaches. LPA Calderon inspected rooms 125, 132, 134 and room 206. All rooms clear and did not find any cockroaches. LPA Calderon checked the dining room, kitchen and common areas and did not see any cockroaches. Records review indicate the following: Dewey Pest Control (dated 10/01/2025 to 12/26/2025), work orders show rooms were treated and common areas showed no sign of cockroaches. Deep cleaning order (dated 01/01/2026) showed room 120 was cleaned and no cockroaches were found. Interviews indicate the following: 5 out of 5 staff deny the allegation. S2 indicates that 20 rooms are treated per day to include room 120. R1 was not in room for interview. 23 out of 24 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff do not ensure the facility is free of cockroaches” is found to be UNSUBSTANTIATED. 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 the Allegation : Staff do not ensure the residents are assisted with meals. This complaint alleged that the facility did not provide meals for residents in care. LPA Calderon toured the facility and noted many residents taking their meals in the dining room. LPA Calderon noted a food cart for those residents that cannot take their meals in the dining room. Resident meals include a food tray and fork, spoon and the meal. Interviews indicate the following: S1 indicates that residents in room 120 takes meals in the room. Staff indicate that meal staff from the dining room provide the residents with meals and a fork. 5 out of 5 staff deny the allegation. R1 was not in room for interview. 23 out of 24 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff do not ensure the residents are assisted with meals is found to be UNSUBSTANTIATED. No deficiencies cited during today's visit. An exit interview was conducted, and a copy of the Complaint Report was provided to the Administrator Colleen Rozatti (S1).

It is being alleged that staff threw away the lunch a resident in care left in residents’ refrigerator. On 12/22/25 and 12/29/25 LPA conducted Interviews with R1-R10 regarding the allegation above. 7 of the 10 residents interviewed denied the allegation above. 1 of the 10 residents interviewed reported that staff will throw away anything in the refrigerator that is no longer good, resident reports being okay with staff doing so. 1 of the 10 residents interviewed reported they do not have a refrigerator in their bedroom therefore does not have any information on the allegation above. 1 of 10 residents interviewed confirmed the allegation above, and reported that staff admitted to doing so per supervisor’s orders. On 12/22/25 and 12/29/25 LPA conducted interviews with S1-S6 regarding the allegation above. 4 of the 6 staff interviewed denied the allegation above. 2 of the 6 staff interviewed confirmed the allegation above and stated that food is only thrown away if it is rotten or molded. Per the 2 of 6 staff who confirmed the allegation above, the resident is informed of what was thrown and why. 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 conducted, and a copy of this report was provided.

It is being alleged that residents in memory care may have scabies, and the facility is unable to control the spread of scabies. On 12/18/25 from 10:00 am- 12pm LPA conducted Interviews with R1-R10 regarding the allegation above. 10 of 10 residents interviewed denied the allegation above, 2 residents reported having rashes that are being treated. On 12/18/25 from 1pm-1:45pm LPA conducted interviews with S1-S5 regarding the allegation above. 5 of 5 staff interviewed denied the allegation above. 1 of the 5 staff interviewed stated that there was a resident that was taken to urgent care for scratching, however it was determined that the scratching was due to an allergic reaction for a medication that has since been discontinued. On 12/24/25 LPA conducted a review of after visit summary dated: 11/12/25, it is indicated in the after visit summary that R1 was seen for generalized rash which was found to likely be an allergic reaction and was provided with a prescription. Allegation: Staff do not ensure residents’ hygiene needs are being met. It is being alleged that residents are not being bathed properly and are dressed in dirty clothes. On 12/18/25 from 10:00 am- 12pm LPA conducted Interviews with R1-R10 regarding the allegation above. 7 of the 10 residents interviewed reported they do not require assistance with bathing needs, 3 of 10 residents reported obtaining bathing assistance from staff .10 of 10 residents interviewed denied the being dressed in dirty clothes. On 12/18/25 from 1pm-1:45pm LPA conducted interviews with S1-S5 regarding the allegation above. 5 of 5 staff interviewed denied the allegation above. On 12/24/25 LPA conducted a review of laundry schedule. Per laundry schedule, laundry is done daily, each resident gets their laundry done once a week unless the service plans indicate that a resident requires laundry service multiple times a week. Allegation: Staff do not ensure that residents have clean bedding. It is being alleged that residents' bedding isn't being changed. On 12/18/25 from 10:00 am- 12pm LPA conducted Interviews with R1-R10 regarding the allegation above. 10 of 10 residents interviewed denied the allegation above. On 12/18/25 from 1pm-1:45pm LPA conducted interviews with S1-S5 regarding the allegation above. 5 of 5 staff interviewed denied the allegation above, and reported linen exchange is done weekly, unless a resident has an accident then linen exchange is done more than once a week. On 12/18/25 LPA conducted tour of the facility and observed laundry actively being done, LPA observed 5 bedrooms that were observed to have clean linen. On 12/24/25 LPA conducted a review of laundry schedule. Per laundry schedule, laundry is done daily, each resident gets their laundry done once a week unless the service plans indicate that a resident requires laundry service multiple times a week. 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 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 conducted, and a copy of this report was provided.

It is being alleged that residents in care are missing appointments due to staff not providing assist in a timely manner. On 10/07/25 and 10/08/25 LPA conducted interviews with S1-S5 regarding the allegation above. 5 of 5 residents interviewed denied the allegation above, per 5 of 5 staff residents have refused assistance and have refused to attend medical appointments. O n 10/08/25 from 1:45 pm-2:15 pm LPA conducted interviews with R2-R10 regarding the allegation above. 9 of 9 residents interviewed denied the allegation above, 1 of 9 residents reported they have refused to attend scheduled medical appointment. On 10/07/25 and 10/08/25 LPA attempted to conduct interview with R1, however R1 refused interview. On 10/08/25 LPA conducted a review of R1's file. LPA conducted review of facility notes, LPA observed documentation indicating R1 has refused medical appointments on multiple occasions. Allegation: Facility staff failed to provide transportation to resident to and from medical appointment. It is being alleged that the facility is not providing residents in care with transportation to and from medical appointments. On 10/07/25 and 10/08/25 LPA conducted interviews with S1-S5 regarding the allegation above, 5 of 5 residents interviewed denied the allegation above. Per 5 of 5 staff, some residents have Access accounts, some residents are transported by families, and some obtain assistance by the facility. On 10/08/25 from 1:45 pm-2:15 pm LPA conducted interviews with R2-R10 regarding the allegation above. 9 of 9 residents interviewed denied the allegation above, 5 of 9 residents reported having their own means of transportation, 1 of 9 residents reported the facility assist with all medical appointments, 1 of 9 residents is now aware of how they get to medical appointments, 2 of 9 residents reported that a physician comes to the facility to see them. On 10/07/25 and 10/08/25 LPA attempted to conduct interview with R1, however R1 refused interview. On 10/08/25 LPA conducted a review of R1's file. LPA conducted review of facility notes, LPA observed documentation indicating R1 has cancelled transportation arrangements on multiple occasions. 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 conducted, and a copy of this report was provided.

The investigation revealed the following: Allegation: Staff did not keep the facility free of rodents. It is alleged that a resident in care observed 6 rodents in the residents’ bedroom. On 09/24/25 from 9:30am-12:00 pm LPA conducted Interviews with R2-R10 regarding the allegation above. 6 of the 9 residents interviewed denied the allegation above. 3 of the 9 residents interviewed confirmed the allegation above and reported observing pest, per the 3 of 9 residents interviewed pest was reported to staff and staff services bedrooms. Additionally, 9 of 9 residents reported bedrooms being cleaned daily by staff, and 8 of 9 residents interviewed confirmed that the facility has a pest services come out to service. On 09/26/25 LPA conducted an interview with R1 regarding the allegation above, per R1 staff have addressed R1’s concerns and R1 has not observed any rodents in bedroom. On 09/24/25 from 1:35pm- 2:32pm LPA conducted interviews with S1-S6 regarding the allegation above, 6 of the 6 staff interviewed denied the allegation above. Per 6 of the 6 staff interviewed, the facility common areas, and bedrooms are cleaned daily. 6 of 6 staff also confirmed that the facility has a pest control contract, and that pest control comes out regularly to service the facility. 6 of the 6 staff interviewed also stated that if and when a resident reports observing pest, a work order will be created, maintenance staff will inspect, and pest control will come out to further service the reported area. On 09/24/25 LPA conducted a check of bedrooms: 119, 135, 137, 217, ML 21, and ML22, LPA observed bedrooms to be clean and pest free. On 09/26/25 LPA conducted a review of the work order dated 09/17/25, per work order resident’s bedroom was inspected for mice infestation and a hole behind residents’ refrigerator. On 09/26/25 LPA conducted a review of Dewey pest control service agreement, per agreement 10 bedrooms are treated weekly as well as common areas, and the building exterior. Per Dewey pest control service agreement dated 9/18/25 resident’s bedroom was inspected and there was no activity found. A review of the housekeeping schedule was conducted, and it reads that every housekeeper cleans 8 bedrooms per shift. Bedrooms are deep cleaned once a week. 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 conducted, and a copy of this report was provided to Sidonia Cordis.

Continued LIC9099-C, page 2 Investigation revealed the following: Allegation: Staff do not ensure the residents' dietary care plan is being followed. On 04/28/2025, the Department interviewed staff members #1-#5 (S1-S5) and residents #1-#10 (R1-R10) regarding the allegation. Five out of five (5 out of 5) staff members and nine out of ten (9 out of 10) residents stated that staff ensure residents' dietary care plans are being followed. They confirmed that staff consistently adhere to physician-prescribed dietary menus and that residents are served well-balanced, nutritious meals according to the doctors' orders. 5 out of 5 staff members and 9 out of 10 residents also stated that the facility does have a dietitian. R1 reported that staff do not ensure the residents' dietary care plans are being followed. LPA requested R1's physicians' report and reviewed the resident's special diet documentation. 5 out of 5 staff members confirmed that R1 is on a diabetic diet, and R1's physician's report, dated 05/28/2024, also indicated that R1 is on a diabetic diet. LPA observed both the facility's regular menu as well as the diabetic alternative menu available for residents on a special diet. Staff stated that according to the residents' physicians' orders, they will accommodate special diets, including low sugar, carbohydrate, mechanical soft, and pureed options. S1-S5 and R2-R10 all denied the allegation. Allegation: Staff do not ensure the resident is provided with breakfast, lunch, and dinner each day. On 04/28/2025, the Department interviewed staff members #1-#5 (S1-S5) and residents #1-#10 (R1-R10) regarding the allegation. All five staff members (5 out of 5) and nine out of ten residents (9 out of 10) stated that staff ensure the residents are provided with breakfast, lunch, dinner, and snacks. Residents (9 out of 10) confirmed they receive three meals per day, and alternative food choices are offered. The facility provides a diverse range of food options, and if a resident requests a second serving, staff accommodate the request. Residents #2-#10 (R2-R10) stated they receive plenty of food to eat, and if they don't want to dine in the dining lounge, they can complete a tray service request. Staff will collect the request slip and deliver the meal to the resident's room. R1 stated that staff do not ensure residents are provided with breakfast, lunch, and dinner each day. LPA observed residents eating lunch and dinner and reviewed the food menus. LPA also observed an ample supply of perishable and non-perishable food items, as well as staff serving meals during breakfast and lunch. Additionally, LPA reviewed the resident's tray service form. S1-S5 and R2-R10 all denied the allegation. Staff members #1-#5 (S1–S5) and residents #2-#10 (R2–R10) all denied the allegation. See continued LIC9099-C 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 Continued LIC9099-C page 3 Allegation: Staff do not ensure adequate care and supervision are provided to residents On 04/28/2025, between 10:00 a.m. and 11:30 a.m., the Department interviewed five (5) staff members identified as Staff #1 through #5 (S1-S5), regarding the allegation that staff do not ensure adequate care and supervision is provided to residents. The concern involved an incident in which a resident allegedly entered Resident #1's (R1) room without permission while R1 was sleeping. Staff #1, #3, #4, and #5 (4 out of 5) staff members stated they had no knowledge of any resident entering R1's room without permission while R1 was sleeping, and that this matter was never brought to their attention. S #2 stated that R1 reported another resident had entered their room; however, there were no witnesses to the incident, and a review of the facility’s surveillance cameras dated 04/20/2025 did not reveal any unauthorized entry. S2 also stated maintenance checked R1's door and confirmed it was in operable condition. All five staff members (5 out of 5) stated that adequate care and supervision are provided to all residents. 5 out of 5 staff members explained that care staff conduct wellness checks on residents every two hours. 5 out of 5 staff members stated that residents have pendants and call buttons to alert staff if they need assistance. 5 out of 5 staff members confirmed that no unauthorized individuals were observed entering residents’ rooms. 5 out of 5 staff members stated residents’ doors remain locked, and each resident has a personal key to their own room. S1-S5 reported that the facility currently has about 93 staff members employed and is fully staffed, and that residents are receiving appropriate care, supervision, and assistance with their daily needs. All five staff members interviewed (5 out of 5) confirmed the facility is sufficiently staffed and denied the allegation. On 04/28/2025, the Department observed R1's room and confirmed the doorknob was in operable condition; once locked, the door required a key to be unlocked. The surveillance footage dated April 20, 2025, did not show a resident entering Resident #1's room at night. See continued LIC9099-C 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 Continued LIC9099-C page 4 On April 28, 2025, between 11:45 a.m. and 12:00 p.m., the Department reviewed the facility’s Personnel Report (LIC 500), which listed the following staff positions: Executive Director; Human Services Director; Vice President of Operations; Business Office Manager; Human Resources Director; Resident Care Director; ALW Coordinator; 4 Licensed Vocational Nurses (LVNs); 2 Community Liaisons; 2 Maintenance Staff; 4 Cooks; 5 Kitchen Staff; 4 Food Servers; 2 Dishwashers; 6 Dietary Aides; 9 Medication Technicians; 7 Memory Care Caregivers; 1 Memory Care Activity Director; 2 Activities Assistants; 25 Caregivers; 7 Housekeepers; 4 Receptionists; and 1 Driver a total number of employees listed: 93, confirmed the facility is adequately staffed. On April 20, 2025, there were 10 staff members on the night shift at 9:30 p.m. No incident reports were filed regarding the allegation. None of the caregivers reported witnessing anything, and nothing was documented or found in the residents' records. On April 28, 2025, between 12:00 p.m. and 2:30 p.m., on the same day, the Department conducted interviews with ten residents #1-#10 (R1–R10) regarding the allegation of inadequate care and supervision. 9 out of 10 residents stated that the facility is adequately staffed and confirmed they are receiving the necessary care and supervision. 9 out of 10 also states that staff are consistently present every shift. 1 out of 10 residents expressed concern about staffing and did not feel care and supervision were adequate. Nine out of ten (9 out of 10) residents reported that they were happy living at the facility and had no problems or complaints. The majority of residents (9 out of 10) denied the allegation and stated that their daily needs were being met. Based on interviews, available evidence, observation, information received, and records reviewed, there was not enough sufficient evidence to support the allegations. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is deemed unsubstantiated. LPA Bunker provided Executive Director Brittney Buchannan with copies of the LIC9099 and LIC9099Cs Complaint Investigation Reports. There were no deficiencies cited. An exit interview was conducted.

On 09/10/25 and 09/11/25 LPA conducted interviews with S1-S7 regarding the allegation above, 7 of the 7 staff interviewed denied the allegation above. On 09/11/25 LPA conducted interview with W1 regarding the allegation above, per W1 there are no safety concerns. Allegation: Staff did not prevent residents from smoking in their bedroom. It is being alleged that facility staff are allowing residents in care to smoke cigarettes in their bedroom and bedroom balcony. On 09/10/25 and 09/11/25 LPA conducted Interviews with R1-R11 regarding the allegation above. 10 of the 11 residents interviewed denied the allegation above. 1 of the 11 residents interviewed confirmed the allegation above and reported calling staff members for help, however, by the time the staff arrives to the bedroom the resident smoking is no longer in the bedroom and there is no evidence that smoking occurred. On 09/10/25 and 09/11/25 LPA conducted interviews with S1-S7 regarding the allegation above, 6 of the 7 staff interviewed denied the allegation above, however report that residents that have been caught smoking in a bedroom are redirected to the smoking patio and are reminded of the facility rules. 1 of the 7 staff interviewed did not have any information regarding the allegation above. On 09/11/25 LPA conducted interview with W1 regarding the allegation above, per W1 there are no safety concerns. On 09/11/25 LPA conducted review of facility notes dated 8/11/25 and 09/03/25, facility notes indicated that resident in care has made reports of peer smoking in the bedroom, however staff have not observed any proof that cigarette smoking has occurred. Allegation: Staff did not prevent a resident from threatening another resident. It is being alleged that facility staff are not calling the police when a resident is threatened by a peer. On 09/10/25 and 09/11/25 LPA conducted Interviews with R1-R11 regarding the allegation above. 9 of the 11 residents interviewed denied the allegation above and reported feeling safe at the facility. 1 of the 11 residents interviewed denied the allegation above, however stated that a peer has threatened resident but it was not reported to staff. 1 of the 11 residents interviewed confirmed the allegation above and stated that staff was able to assist but the police was not called. On 09/10/25 and 09/11/25 LPA conducted interviews with S1-S7 regarding the allegation above, 7 of the 7 staff interviewed denied the allegation above. On 09/11/25 LPA conducted interview with W1 regarding the allegation above, per W1 there are no safety concerns. 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 conducted, and a copy of this report was provided.

INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Staff are not properly addressing pest infestation in the facility. The complaint states that the staff are not adequately addressing the pest infestation in the facility. It has been reported that Resident #1 (R1) is facing a vermin infestation in their room. Despite multiple attempts to contact the person responsible for resolving the issue, (R1) has been unable to obtain assistance. Additionally, (R1) must deal with exterminating various small and large bugs daily and have experienced pest bites. No further details regarding this matter have been provided. On August 22, 2025, between 09:05 AM and 11:09 AM, the Department interviewed staff members identified as Staff #1 through Staff #6 (S1-S6). Six (6) out of the six (6) staff members expressed that they could not support this claim. (S1-S2) emphasizes its commitment to ensuring the safety and well-being of residents by implementing effective, environmentally friendly pest management measures. The facility has an active service agreement with a reputable pest control company that performs weekly pest control services. (S2) stated that these scheduled services treat ten rooms and common areas each week. (S1-S2) reported that (R1's) room was serviced, with treatments conducted on June 20, 2025, and August 19, 2025, along with adjacent rooms on the same floor. (S1-S6) noted that (R1) has not recently informed staff about any pest issues and prohibits them from entering (R1's) room for cleaning and care assistant services. Furthermore, all six staff members interviewed reported that (R1) has made it clear that they will not permit anyone to enter their room without their presence. They have stated that if this boundary is not respected, they will not hesitate to contact law enforcement or legal counsel to enforce their rights. This situation creates challenges for the facility in maintaining a safe and healthy environment for (R1). On August 22, 2025, between 10:45 AM and 12:08 PM, the Department interviewed resident members identified as Resident #1 through Resident #9 (R1-R9). Seven (7) out of the nine (9) residents could not validate this allegation. Residents from (R3-R9) have stated that they have no issues or concerns as they have not encountered any pest in their rooms or common areas. Additionally, they have observed pest control professionals actively performing treatments throughout the premises, ensuring a safe and pest-free environment for everyone. (R10), identified as( R1's) roommate, declined to be interviewed. (Evaluation Report continues LIC 9099-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 (R1-R2) expressed concerns regarding a pest issue in their rooms and mentioned that they have informed the staff, but no action has been taken yet. (R1) indicated that they have reported the issue to the care staff daily; however, (R1) was unable to recall the names of the staff members involved. Additionally, (R1) did not remember if the room had been treated on June 20, 2025, or August 19, 2025. (R1) verified that staff must not enter the room without the presence of (R1), nor should they provide any cleaning or care assistance services without (R1's) presence. This rule is crucial to maintain proper standards according to (R1's) preference. (R1) stated she has not seek any medical assistance for bites due to pest problems. The Department inspected the facility on August 22, 2025, focusing on the first floor, second floor, and common areas. Rooms inspected included #284, # 285, 286, 287, and #289. The rooms were found to be maintained and clean. The rooms are in order to prevent pest infestations, ensuring a comfortable environment for everyone. Housekeeping and maintenance staff were observed carrying out their responsibilities. (R1's) room was found to be disorganized, with clothes and tableware left soaked for an extended period. There was also standing water, which could attract and create a breeding ground for flies. Additionally, uncovered food packages and drinks left in glassware are likely to attract various types of flies. The Department did not observed any sign vermin or pest infestation. The Department did not observed what appear to be pest bites on (R1). The Department reviewed a Dewey Pest Control Service Agreement dated December 12, 2024, and another dated June 17, 2025, which provided evidence of an annual service contract. This contract indicated that ten service visits were performed each month, totaling 40 treatments per month. Additionally, an examination of the Dewey Pest Control Service Log, covering the period from June 20, 2025, to August 19, 2025, confirmed that service treatments were performed for (R1's) room. Telecommunications records from July 13, 2025, indicated that (R1) had prohibited staff from entering the room for cleaning assistance. Further review conducted on (R1's) Physician's Report LIC 624 A and the Service Plans dated May 25, 2025, and June 21, 2025. (Evaluation Report continues LIC 9099-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 Based on the information gathered, there is not enough evidence to support the allegation mentioned above. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is Unsubstantiated . An exit interview was conducted with Suzette Johnson, and copies of the reports were provided.

It is being alleged that facility kitchen does not provide lunch to go when requested. On 08/19/25 LPA conducted interview with R1 regarding the allegation above, R1 reported the allegation is being addressed however R1 has been dealing with the allegation above for 3 months. on 08/21/25 LPA conducted interview with S1-S2 regarding the allegation above, 2 of 2 staff interviewed denied the allegation above, Per 2 of 2 staff interviewed residents have requested to go meals and the kitchen staff has completed the request. Additionally 2 of 2 staff interviewed reported that the requested packed meal are not always picked up by R1. 1 of 2 staff interviewed reported that the kitchen cooks big quantities of food to ensure that residents who are out during scheduled meal services can have food available upon their arrival. On 08/21/25 LPA reviewed the admission agreement page A-3 letter E titled meals, upon review of the admission agreement, LPA did not observe any documentation stating that the facility will provide packed meals for residents in care. 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 conducted, and a copy of this report was provided.

Investigation consisted of the following: On 07/02/2025, interviews were conducted, and records were gathered. Interviews conducted consisted of 10 resident interviews [Resident 2 (R2) to Resident 11 (R11) were interviewed]. Resident 1’s (R1) records were gathered which consisted of Medication Administration Record (MAR) from 03/2025 to 04/2025; Unusual Incident Report dated 05/16/2025; Progress Notes from 03/2025 to 04/2025; Admission Agreement dated 04/07/2025; Emergency Information dated 07/02/2025; Resident Assessment dated 02/25/2025; Preplacement Appraisal Information dated 02/28/2025; Appraisal/Needs & Services Plan dated 03/05/2025; Consent Forms dated 03/09/2025; Personal Rights dated 03/09/2025; and other pertinent information. Facility records were gathered which consisted of Resident Roster; Personnel Report dated 04/2025; Personnel Report dated 07/02/2025; LVN-Medication Technician Job Role Description; Time-Sheets from 04/05/2025 to 04/06/2025; Fall Risk Mitigation and Prevention Policy; Inservice Training from 03/05/2024 to 03/19/2025; Plan of Operation; and other pertinent information. On 8/14/2025, interviews were conducted, and records were reviewed. Interviews conducted consisted of 9 staff interviews [Staff 1 (S1) to Staff 9 (S9) were interviewed] and 2 witness interviews [Witness 1 (W1) to Witness 2 (W2) were interviewed]. 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: “Resident fell due to staff neglect resulting in injury”, it is being alleged that R1 fell due to staff neglect which resulted in R1 sustaining an injury. Interviews conducted with R2 to R11 revealed the following: 10 out of 10 residents denied the allegation. Interviews conducted with S1 to S9 revealed the following: 9 out of 9 staff denied the allegation. Interviews conducted with W1 to W2 revealed the following: 2 out of 2 witnesses denied the allegation. Records reviewed of R1’s facility notes revealed the following: on 04/05/2025 at 11:15 PM R1 had an unwitnessed fall; R1 was seen by Caregivers and by a Licensing Vocational Nurse; R1 was unhurt. Based on the department’s interviews and records reviewed this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. 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: “Staff did not seek medical attention for resident”, it is being alleged that staff did not seek medical attention for R1. Interviews conducted with R2 to R11 revealed the following: 9 out of 10 residents denied the allegation. 1 out of 10 residents agreed with the allegation. Interviews conducted with S1 to S9 revealed the following: 9 out of 9 staff denied the allegation. Interviews conducted with W1 to W2 revealed the following: 2 out of 2 witnesses denied the allegation. Records reviewed of R1’s unusual incident report dated 04/06/2025 revealed the following: on 04/06/2025 at 3:00 PM, resident had a low oxygen level and 911 was called. Based on the department’s interviews and records reviewed this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were provided. An exit interview was conducted, and a copy of this report was left with the Executive Director, Suzette Johnson.

The investigation revealed the following: Allegation: Staff are not properly addressing pest infestation in the facility. It is being alleged that a resident in care has bugs crawling on body and face throughout the night. On 08/12/25 from 12pm-1:25pm LPA conducted Interviews with R2-R10 regarding the allegation above, 3 of 9 residents interviewed reported observing pest in the bedrooms, and reported having their bedrooms treated after staff was made aware. 6 of 9 residents interviewed denied the allegation above and reported their bedrooms have been treated for pest as a precaution. On 08/12/15 LPA unable to interview R1 as R1 refused interview. On 08/12/25 from 1:35pm- 2:32pm LPA conducted interviews with S1-S5 regarding the allegation above, 5 of 5 staff interviewed denied the allegation above, and reported that R1 does not allow staff to come into R1's bedroom to provide cleaning services. Additionally 5 of 5 staff interviewed stated that R1 threatens to call law enforcement and a Lawyer if staff attempt to enter R1's bedroom. On 08/12/25 LPA conducted a review of Dewey pest control services logs, per service log R1's bedroom was services on 6/20/25. LPA conducted a review of Dewey pest control service agreement, per agreement 10 bedrooms are treated weekly as well as common areas, and the building exterior. On 08/12/25 LPA conducted a review of communication notes, LPA observed documented communication from staff reported that R1 does not allow entry into R1's bedroom. 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 conducted, and a copy of this report was provided.

The investigation revealed the following: Allegation 1: Licensee did not ensure bathroom was in good repair. It was alleged bathroom, is not working for days and they have not ask someone to come fix it. On 07/17/2025 at 10:45am - 10:54am, LPA interviewed A1. A1 who denied the allegation, stated she is not aware of any recent issues with R1's bathroom and residents can report to the front desk where a work order is placed and maintenance will complete the order. Between 8:51am - 10:06am, LPA interviewed 10 staff the regarding the allegation: 2 of out of 10 staff confirmed the allegation. 7 out of 10 staff denied the allegation. 1 out of 10 staff were unsure of the allegation. Between 9:49 AM - 10:59 AM, LPA interviewed 9 residents: 8 out of 9 residents denied the allegation. 1 out of 9 residents unsure or unaware of the allegation. On 07/17/2025 at approximately 1:03pm and on 08/06/2025 between the hours of 11:09am - 11:29am LPA conducted a tour with S9 of the following rooms 118,135,208,211,237,247,283,285 and 306 & observed the following: the sink, shower and toilet are operable and in good repair . On 07/17/2025 at approximately 1:30pm, LPA conducted a records review of the work order (created on 06/25/2025) and did not observe any documentation to support the allegation. Based on interviews conducted, records review and observation there is no evidence to support the allegation, therefore the allegation is UNSUBSTANTIATED. Allegation 2: Licensee did not ensure required notices were visibly posted in the facility. It was alleged that the facility its just plain walls with no emergency information or telephone. On 07/17/2025 at 10:45am - 10:54am, LPA interviewed A1. A1 who denied the allegation, stated the required posting are publicly visible in the common areas of the facility which is a standard protocol. Between 8:51am - 10:06am, LPA interviewed 10 staff regarding the allegation: 10 out of 10 staff denied the allegation. Between 9:49 AM - 10:59 AM, LPA interviewed 9 residents: 3 out of 9 residents confirmed the allegation. 4 out of 9 residents denied the allegation. 2 out of 9 residents were unsure or unaware of the allegation. On 07/17/2025 between the hours of 8:35am -8:40am, LPA conducted a tour of the facility with S8 and observed in the main lobby area posted on the wall are following: the facility license, the Emergency Disaster Plan for Residential Facilities, the Long Term Ombudsman contact information (also posted on the 2nd floor in the library area which was observed during the tour by LPA with S9 on 08/06/2025 between the hours of 11:09am - 11:28am), and the California Department of Social Services Community Care Licensing Division Centralized Complaint & Information Bureau contact information. Report continues on 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 On 08/06/2025, between the hours of 11:09am - 11:28am, LPA conducted a tour with S9 and observed a working telephones at the front desk, the first and the second floor of the facility which are easily accessible for all residents to use. Based on interviews conducted and observation there is no evidence to support the allegation, therefore the allegation is UNSUBSTANTIATED. Allegation 3: Staff did not allow resident to leave their room. It was alleged the facility won't let resident out of the room. On 07/17/2025 at 10:45am - 10:54am, LPA interviewed A1. A1 who denied the allegation, stated residents are only restricted from common areas in the event that a resident is on isolation due to testing positive for COVID. Between 8:51am - 10:06am, LPA interviewed 10 staff the regarding the allegation: 10 out of 10 staff denied the allegation. Between 9:49 AM - 10:59 AM, LPA interviewed 9 residents: 9 out of 9 residents denied the allegation. Between the hours of 8:35am -8:40am, LPA conducted a tour of the facility and observe residents throughout the facility in common area. Upon records review, R1 is diagnosed with dementia as stated in R1's - LIC 602A Physician's Report for Residential Care Facilities for the Elderly (RCFE). On the LIC 602 under Section 14. Mental Condition it states (k). Able to Leave Facility Unassisted is check of NO. Based on interviews conducted and observation there is no evidence to support the allegation, therefore the allegation is UNSUBSTANTIATED. On 07/17/2025, LPA attempted to interview Resident #1 (R1) who declined to be interviewed about the three allegations. 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 allegations are UNSUBSTANTIATED. Exit interview conducted with Suzette Johnson (Administrator) & copy of the report was provided.

Continued LIC9099-C page 2 Investigation revealed the following: Allegation: Staff do not ensure residents' dietary care plan is being followed. On 04/28/2025, the Department interviewed staff members #1-#5 (S1-S5) and residents #1-#10 (R1-R10) regarding the allegation. Five out of five (5 out of 5) staff members and nine out of ten (9 out of 10) residents stated that staff ensure residents' dietary care plans are being followed. They confirmed that staff consistently adhere to physician-prescribed dietary menus and that residents are served well-balanced, nutritious meals according to the doctors' orders. 5 out of 5 staff members and 9 out of 10 residents also stated that the facility does have a dietitian. R1 reported that staff do not ensure the residents' dietary care plans are being followed. LPA requested R1's physicians' report and reviewed the resident's special diet documentation. 5 out of 5 staff members confirmed that R1 is on a diabetic diet, and R1's physician's report, dated 05/28/2024, also indicated that R1 is on a diabetic diet. LPA observed the facility's regular menu as well as the diabetic alternative menu available for residents on a special diet. Staff stated that according to the residents' physicians' orders, they will accommodate special diets, including low sugar, carbohydrate, mechanical soft, and pureed options. S1-S5 and R2-R10 all denied the allegation. Allegation: Staff do not ensure the resident is provided with breakfast, lunch, and dinner each day. On 04/28/2025, the Department interviewed staff members #1-#5 (S1-S5) and residents #1-#10 (R1-R10) regarding the allegation. Staff members (5 out of 5) and 9 out of 10 residents stated that staff ensure the residents are provided with breakfast, lunch, dinner, and snacks. Residents confirmed they receive three meals per day, and alternative food choices are offered. The facility provides a diverse range of food options, and if a resident requests a second serving, staff accommodates the request. R2-R10 stated they receive plenty of food to eat, and if they don't want to dine in the dining lounge, they can complete a tray service request. Staff will collect the request slip and deliver the meal to the resident's room. R1 stated that staff do not ensure residents are provided with breakfast, lunch, and dinner each day. LPA observed residents eating lunch and dinner and reviewed the food menus. LPA observed an ample supply of perishable and non-perishable food items. LPA observed staff serving meals during breakfast and lunch. LPA also reviewed the resident's tray service form. S1-S5 and R2-R10 all denied the allegation. See continued LIC9099-C 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 Continued LIC9099-C page 3 Allegation: Staff do not ensure adequate care and supervision is provided to residents On 04/28/2025, between 10:00 a.m. and 11:30 a.m., the Department interviewed two staff members #1 and #5 (S1-S5), regarding the allegation. S2 stated that a resident reported another resident had entered their room; however, there were no witnesses to the incident, and a review of the facility’s surveillance cameras did not reveal any unauthorized entry. Maintenance checked the resident's door and confirmed it was in operable condition. S1 and S5 explained that care staff conduct Wellness checks on residents every two hours. All residents have pendants and call buttons to alert staff if they need assistance. Staff confirmed that no unauthorized individuals were observed entering residents’ rooms. S1 and S5 stated residents’ doors remain locked, and each resident has a personal key to their own room. S1-S5 states the facility currently has about 93 staff members employed and is fully staffed, and that residents are receiving appropriate care, supervision, and assistance with their daily needs. Both interviewed staff (5 out of 5) confirmed the facility is sufficiently staffed and denied the allegation. On April 28, 2025, between 11:45 a.m. and 12:00 p.m., the Department reviewed the facility’s Personnel Report (LIC 500), which listed the following staff positions: Executive Director; Human Services Director; Vice President of Operations; Business Office Manager; Human Resources Director; Resident Care Director; ALW Coordinator; 4 Licensed Vocational Nurses (LVNs); 2 Community Liaisons; 2 Maintenance Staff; 4 Cooks; 5 Kitchen Staff; 4 Food Servers; 2 Dishwashers; 6 Dietary Aides; 9 Medication Technicians; 7 Memory Care Caregivers; 1 Memory Care Activity Director; 2 Activities Assistants; 25 Caregivers; 7 Housekeepers; 4 Receptionists; and 1 Driver a total number of employees listed: 93, confirmed the facility is adequately staffed. On April 20, 2025, there were 10 staff members on the night shift at 9:30 p.m. No incident reports were filed regarding the allegation. None of the caregivers reported witnessing anything, and nothing was documented in the residents' records. See continued LIC9099-C 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 Continued LIC9099-C page 4 On April 28, 2025, between 12:00 p.m. and 2:30 p.m., on the same day, the Department conducted interviews with ten residents #1-#10 (R1–R10) regarding the allegation of inadequate care and supervision. 9 out of 10 residents stated that the facility is adequately staffed and confirmed they are receiving the necessary care and supervision. 9 out of 10 also stated that staff are consistently present every shift. 1 out of 10 residents expressed concern about staffing and did not feel care and supervision were adequate. 9 out of 10 residents reported that they were happy living at the facility and had no problems or complaints. The majority of residents (9 out of 10) denied the allegation and stated that their daily needs were being met. Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegations. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed unsubstantiated. There were no deficiencies cited. An exit interview was conducted.

The investigation revealed the following: Allegation 1: Licensee did not ensure bathroom was in good repair. It was alleged bathroom, is not working for days and they have not ask someone to come fix it. On 07/17/2025 at 10:45am - 10:54am, LPA interviewed A1. A1 who denied the allegation, stated she is not aware of any recent issues with R1's bathroom and residents can report to the front desk where a work order is placed and maintenance will complete the order. Between 8:51am - 10:06am, LPA interviewed 10 staff the regarding the allegation: 2 of out of 10 staff confirmed the allegation. 8 out of 10 staff denied the allegation. Between 9:49 AM - 10:59 AM, LPA interviewed 9 residents: 8 out of 10 residents denied the allegation. 1 out of 10 residents were unsure or unaware of the allegation. At approximately 1:03pm, LPA conducted a tour of room 285 where Resident 1 (R1) resides and observed the following: the sink, shower and toilet operable and in good repair. At approximately 1:30pm, LPA conducted a records review of the work order (created on 06/25/2025) and did not observe any documentation to support the allegation. Based on interviews conducted, records review. and observation there is no evidence to support the allegation, therefore the allegation is UNSUBSTANTIATED Allegation 2: Licensee did not ensure required notices were visibly posted in the facility. It was alleged that the facility its just plain walls with no emergency information or telephone. On 07/17/2025 at 10:45am - 10:54am, LPA interviewed A1. A1 who denied the allegation, stated the required posting are publicly visible in the common areas of the facility which is a standard protocol. Between 8:51am - 10:06am, LPA interviewed 10 staff the regarding the allegation: 10 out of 10 staff denied the allegation. Between 9:49 AM - 10:59 AM, LPA interviewed 9 residents: 3 out of 9 residents confirmed the allegation. 4 out of 9 residents were unsure or unaware of the allegation. 2 out of 9 residents denied the allegation. Between the hours of 8:35am -8:40am, LPA conducted a tour of the facility and observed in the main lobby area posted on the wall are following: the facility license, the Emergency Disaster Plan for Residential Facilities, the Long Term Ombudsman contact information, and the California Department of Social Services Community Care Licensing Division Centralized Complaint & Information Bureau contact information. Based on interviews conducted and observation there is no evidence to support the allegation, therefore the allegation is UNSUBSTANTIATED. Report continues on LIC 9099 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 3: Staff did not allow resident to leave their room. It was alleged the facility won't let resident out of the room. On 07/17/2025 at 10:45am - 10:54am, LPA interviewed A1. A1 who denied the allegation, stated residents are only restricted from common areas in the event that a resident is on isolation due to testing positive for COVID. Between 8:51am - 10:06am, LPA interviewed 10 staff the regarding the allegation: 10 out of 10 staff denied the allegation. Between 9:49 AM - 10:59 AM, LPA interviewed 9 residents: 10 out of 10 residents denied the allegation. Between the hours of 8:35am -8:40am, LPA conducted a tour of the facility and observe residents throughout the facility in common area. Upon records review, R1 is diagnosed with dementia as stated in R1's - LIC 602A Physician's Report for Residential Care Facilities for the Elderly (RCFE). On the LIC 602 under Section 14. Mental Condition it states (k). Able to Leave Facility Unassisted is check of NO. Based on interviews conducted and observation there is no evidence to support the allegation, therefore the allegation is UNSUBSTANTIATED. On 07/17/2025, LPA attempted to interview Resident #1 (R1) who declined to be interviewed about the three allegations. 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 allegations are UNSUBSTANTIATED. Exit interview conducted with Suzette Johnson (Administrator) & copy of the report was provided.

Allegation: Staff are not safeguarding resident's belongings. It is being alleged that someone is stealing money from a resident in care. On 07/15/25 from 10:15 am- 12:18 pm LPA conducted Interviews with R1-R10 regarding the allegation above, 9 of 10 residents interviewed denied the allegation above and stated their money have not been stolen or misplaced at the facility. 1 of 10 residents interviewed confirmed the allegation above, per resident money has gone missing twice, however it was not reported to staff. On 07/15/25 from 1:00pm- 2pm LPA conducted interviews with S1-S6 regarding the allegation above, 6 of 6 staff denied the allegation above. 6 of 6 staff interviewed reported that if a resident reports having their property stolen, staff will document it on the communication log, and report it to management for investigation. On 07/15/25 at 2:30 pm LPA spoke to W1 regarding the allegation above, W1 has no concerns regarding the allegation above. On 07/15/25 LPA conducted a review of R1's file, per physicians report dated: 12/24/24, R1 cannot handle own cash resources, R1 has a financial power of attorney. On 07/15/25 LPA reviewed the Resident theft and loss record, LPA did not observe R1 to be listed as reporting any loss or theft. On 07/15/25 LPA reviewed P&I account log from October 2024-July 2025, per log R1 has been receiving funds weekly. 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 conducted, and a copy of this report was provided.

On 07/09/2025 around 9:00 AM, LPA interviewed Resident (R1). Investigation revealed the following: Interviews conducted revealed the following: 9 out of the 10 staff members did not agree with the allegation, S1 stated that the facility has pest control measures in place and is currently in preventative mode. S2 indicated that kitchen cleaning is performed regularly. 9 out of the 10 residents did not agree with the allegation. R1 indicated that mice have been seen however had been taken care of in a slow manner when it’s brought up to the staff. LPA observations revealed the following: No live rodents were observed at the time of the visits. Records review revealed the following: LPA Anguiano reviewed a Dewey Pest Control Service Agreement, which indicated proof of an annual service contract. This contract indicated that the services are performed monthly on Wednesday’s. Additionally, a review of the Dewey Pest Control Service Log, covering the period from March 1, 2025, and April 29, 2025, confirmed that treatment services are being performed monthly. During this investigation, LPA did not find sufficient evidence to support the above-mentioned allegation. Based on the evidence gathered, interviews conducted, and records reviewed, although the allegation “staff did not keep the facility free of rodents” may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of the Complaint Report was given to Suzette Johnson.

Regarding the Allegation : Staff are not disposing of medications. This complaint alleged that the facility staff did not dispose of resident medication. LPA Calderon toured the facility with S1. LPA Calderon walked into the medication room on the second floor and witnessed staff preparing medications to be given to residents in care. LPA Calderon noted that staff work with an electronic Medication Administration Record (MAR) for dispensing the residents’ medications. The medications were locked in drawers and moved to locked medication carts which are used to move the resident’s medication. LPA Calderon noted there is a disposable bin for expired medications. LPA Calderon was shown the cabinet that holds liquid medications such as eye drops which were stored and locked. Interviews indicate the following: 8 out of 8 staff deny the allegation. 12 out of 12 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “Staff are not disposing of medications.” is found to be UNSUBSTANTIATED. Regarding the Allegation : Staff did not safeguard resident’s medications. This complaint alleged that the facility staff did not safeguard resident’s medications. LPA Calderon toured the facility with S1. LPA Calderon walked into the medication room on the second floor and witnessed staff preparing medications to be given to residents in care. LPA Calderon noted that staff work with an electronic Medication Administration Record (MAR) for dispensing the residents’ medications. The medications were locked in drawers and moved to locked medication carts which are used to move the resident’s medication. LPA Calderon noted there is a disposable bin for expired medications. LPA Calderon was shown the cabinet that holds liquid medications such as eye drops which were stored and locked. Interviews indicate the following: 8 out of 8 staff deny the allegation. 12 out of 12 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “Staff did not safeguard resident’s medications.” is found to be UNSUBSTANTIATED. 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 the Allegation : Staff are not administering medications to residents. This complaint alleged that the facility staff did not administer medication to residents. LPA Calderon toured the facility with S1. LPA Calderon walked into the medication room on the second floor and witnessed staff preparing medications to be given to residents in care. LPA Calderon noted that staff work with an electronic Medication Administration Record (MAR) for dispensing the residents’ medications. The medications were locked in drawers and moved to locked medication carts which are used to move the resident’s medication. LPA Calderon noted there is a disposable bin for expired medications. LPA Calderon was shown the cabinet that holds liquid medications such as eye drops which were stored and locked. Records review indicate the following: Reviewed the MAR for April, May and June 2025 for R1-R9. Medications given to residents with no errors. Reviewed Physician orders for R1-R9, noted staff ordered medications for resident in care. Interviews indicate the following: 8 out of 8 staff deny the allegation. 12 out of 12 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “Staff are not administering medications to residents.” is found to be UNSUBSTANTIATED. Regarding the Allegation : Staff are not following residents care plans. This complaint alleged that the facility staff did not follow the residents’ care plan. Records review indicate the following: Reviewed service plan for R1-R9, staff following service plan. Reviewed Physician report for R1-R9, staff following physician report for residents in care. Interviews indicate the following: 8 out of 8 staff deny the allegation. 12 out of 12 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “Staff are not following residents care plans” is found to be UNSUBSTANTIATED. 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 the Allegation : Staff left residents in a soiled diaper for a long period of time. This complaint alleged that the facility staff did not dispose of soiled diapers for a long period of time. Records review indicate the following: Service plan for R1-R2 indicates full assistance with all aspects of bathroom activities and hygiene. Shower and Toileting logs indicate that bathing, grooming and toileting are provided to R1-R2 multiple times per day or per week. Interviews indicate the following: 8 out of 8 staff deny the allegation. 12 out of 12 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “Staff left residents in a soiled diaper for a long period of time.” is found to be UNSUBSTANTIATED. Regarding the Allegation : Staff are not bathing residents in care. This complaint alleged that the facility staff did not bathe residents. Records review indicate the following: Reviewed Service plan for R1-R9, assistance needed for showering noted by staff. Shower and Toileting logs indicate that bathing, grooming and toileting are provided to R1-R2 multiple times per day or per week. Interviews indicate the following: 8 out of 8 staff deny the allegation. 12 out of 12 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “Staff are not bathing residents in care.” is found to be UNSUBSTANTIATED. Regarding the Allegation : Staff are not feeding residents in care. This complaint alleged that the facility staff did not feed bedbound residents. Records review indicate the following: Reviewed Weekly Menu for residents in care, noted wide range of options to eat for residents. Breakfast, lunch and dinner are served. There is 1 st seating and 2 nd seating starting at 7am to 9am, lunch from 11 am to 1pm and dinner from 4pm to 6pm. Alternative menu is offered. Standard admission agreement indicates page A3-A4, section E meals: We will serve 3 nutritionally balanced meals and snacks daily to residents. Tray Service, we will provide a tray service to your apartment during an illness at no extra charge. Interviews indicate the following: 8 out of 8 staff deny the allegation. 12 out of 12 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “Staff are not feeding residents in care.” is found to be UNSUBSTANTIATED 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 the Allegation : Staff are teasing residents in care. This complaint alleged that the facility staff did not treat residents with respect. Toured the facility and did not notice any negative interactions with residents in care. Interviews indicate the following: 8 out of 8 staff deny the allegation. 12 out of 12 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “Staff are teasing residents in care.” is found to be UNSUBSTANTIATED. No deficiencies cited during today's visit. An exit interview was conducted, and a copy of the Complaint Report was provided to the Administrator Suzette Johnson (S1).

The investigation revealed the following: Allegation: Resident sustained an unexplained injury while in care. It is being alleged that a resident in care had swelling and bruising around their right eye that was not there 2 days prior. On 06/18/25 at 10:00 am-11:45am LPA conducted Interviews with R2-R10, 9 of 9 residents interviewed denied the allegation above, and reported feeling safe living at the facility. On 06/18/25 and 6/27/25 LPA conducted interviews with S1-S8 regarding the allegation above, 8 of 8 staff interviewed denied the allegation above. Per 8 of 8 staff interviewed, families and Primary Care Physicians are notified of any falls or injuries a resident may experience while in care. On 06/26/25 LPA conducted a review of R1's file, LPA observed incident reports dated: 05/19/25, 06/04/25, and 06/16/25, per incident reports R1 experienced un-witnessed falls and declined medical attention. LPA confirmed incident reports dated: 05/19/25, 06/04/25, and 06/16/25 were sent and received by CCLD. During file review LPA observed documented fall risk assessments conducted on 06/04/25, 06/09/25, and 06/16/25, per fall risk assessments R1 was at high risk of falls. In addition, during file review LPA observed an order from provider dated 6/16/25 for residents to be sent to ER due to recent falls and refusal of medical attention. On 06/27/25 LPA conducted telephone interview with R1 regarding the allegation above, R1 denied the allegation above. Per R1, R1 is clumsy and has fallen quite a bit. R1 states that the facility has offered medical service after each fall, however R1 did not see it necessary as R1 is able to take care of self. R1 stated the staff at Vista Del Mar have been very kind since R1’s has been admitted. 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 conducted, and a copy of this report was provided.

The investigation revealed the following: Allegation #1- Staff did not prevent resident from engaging in inappropriate behaviors. The details of the complaint alleged that the resident (R1) has a roommate that is sundowning and is up during the night, and R1 has caught the roommate messing with their oxygen tank. It was reported that the resident feels unsafe with their current roommate and would like to change rooms. On 7/1/25, from 10:00am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R10) regarding the allegation. 4 of 4 staff denied the allegation that the Staff did not prevent resident from engaging in inappropriate behaviors. All staff (S1-S4) interviewed stated that they had no knowledge that R1s roommate had allegedly interfered with their oxygen tank. They stated that no one told them about this issue and now that they know they will address the issue and take appropriate action. The department interviewed residents (R1-R10) about the allegation and 9 of 10 residents that were interviewed denied any knowledge of ongoing issues with resident’s engaging in inappropriate behaviors. The majority of the resident’s stated that they either do not have a roommate or that they do not have any such issues with their current roommate and/or other resident’s. The Department reviewed the Vista Del Mar Senior Living Work Order (Dated: 06/28/2025) and Facility Notes (Dated: 07/01/2025) and observed that a work order was created on 06/28/2025 to move the resident (R1) to another room in the facility. The department also observed that management was made aware of the issue between the two roommates and started the process of taking appropriate actions to resolve the concern. S1 stated that R1 was given an option to switch sides within the room to help resolve the disagreement but R1 declined the offer and chose to stay on their side of the room. Subsequently, the facility decided to move R1 and created a work order to do so on 06/28/2025. R1 is scheduled to be transferred to a new room within a week or so. Once the room has been prepped, the team will assist R1 with their move to their new location in the facility. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff did not prevent resident from engaging in inappropriate behaviors. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated . Report Continued On LIC9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation #2- Staff are not providing a comfortable environment for resident. The details of the complaint alleged that the resident (R1) has a roommate that is causing the resident to live in an uncomfortable environment, but the facility has not moved or changed the resident to a new room. It was reported that the roommate and their family members turn off the air condition in the bedroom when it is hot, causing the resident (R1) to feel uncomfortable. On 7/1/25, from 10:00am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R10) regarding the allegation. 4 of 4 staff denied the allegation that the Staff are not providing a comfortable environment for resident. All staff (S1-S4) interviewed stated that when they learned of the issue with the roommates, they took appropriate action to resolve the issue. They stated that they had a discussion with both resident’s and concluded that they would relocate R1 to another room in the facility. Staff stated that they are in the process of making that happen and it should not take more than a week to find a room and prepare it for R1 to move in. They further state that R1 will be assisted with the move by a team within the facility. The department interviewed residents (R1-R10) about the allegation and 9 of 10 residents that were interviewed stated that they were comfortable with the environment within the facility and were satisfied with the care and supervision provided by the staff. The majority of the resident’s stated that they are provided a comfortable environment to live in by the facility. The Department reviewed the Vista Del Mar Senior Living Work Order (Dated: 06/28/2025) and Facility Notes (Dated: 07/01/2025) and observed that a work order was created on 06/28/2025 to move the resident (R1) to another room in the facility. The department also observed that management was made aware of the issue between the two roommates and started the process of taking appropriate actions to resolve the concern. R1 is scheduled to be transferred to a new room within a week or so. Once the room has been prepped, the team will assist R1 with their move to their new location in the facility. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff are not providing a comfortable environment for resident. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated . No deficiencies were cited. An exit interview was conducted with Suzette Johnson, Executive Director, and a hard copy of this Complaint Investigation Report was provided.

The investigation consisted of the following: LPA Watson conducted interviews with residents and staff. LPA Watson requested and received the following: Staff and Resident Roster, SIR reports, Physician's report.A tour of the facility was conducted with the Administrator Suzette Johnson on 05/13/2025. The investigation revealed the following: Allegation: Staff did not ensure resident's catheter care was properly managed. It is being alleged that staff did not ensure that resident’s catheter was regularly emptied and cleaned. On 05/08/2025 the department conducted interviews with Residents #2 - Residents #11 (R2-R11). An attempt to interview Resident #1 (R1) was made but they were no longer at the facility and did not respond to several calls and messages left on their phone/voice mail. The department asked the residents if staff catheters were properly emptied, cleaned and managed? Of those interviewed, 10 out of 10 residents denied the above allegation. On 05/08/2025 the department interviewed Staff #1- Staff #11 (S1-S11). The department asked the staff if catheters were properly emptied, cleaned and managed? Of those interviewed, 11out of 11staff denied the above allegation. Based on interviews and observations there is insufficient evidence to support the allegation: Staff did not ensure resident’s catheter care was properly managed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted with the Administrator Suzette Johnson and a copy of this report was provided.

The investigation revealed the following: Allegation: Staff did not ensure resident's catheter care was properly managed. It is being alleged that staff did not ensure that resident’s catheter was regularly emptied and cleaned. On 05/08/2025 the department conducted interviews with Residents #1- Residents #10 (R1-R10). The department asked the residents if their catheters were properly emptied, cleaned and managed. Of those interviewed, 1 out of 10 residents had a catheter and stated he had no issues with staff’s management of his catheter while the out 9 of 10 residents did not have catheters but had not heard about anyone having issues with their catheters. On 05/08/2025 the department interviewed Staff #1- Staff #11 (S1-S11). The department asked staff if catheters were properly emptied, cleaned and managed. Of those interviewed, 11 out of 11staff denied the allegation. Based on interviews and observations there is insufficient evidence to support the allegation: “Staff did not ensure resident’s catheter care was properly managed”. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted with the Administrator Suzette Johnson and a copy of this report was provided.

INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Staff does not provide comfortable water temperature for resident(s). The complaint details the staff allegedly failing to provide a comfortable water temperature for residents in care. Reports indicate that there is no hot water available. The common shower area fails to provide consistent hot water, and despite notifying a staff member about this issue, no actions have been taken to resolve it, and no further information has been provided. On May 1, 2025, between 9:30 AM and 10:30 AM, the Department interviewed staff members identified as Staff #1 through Staff #5 (S1-S5). Five (5) out of the (5) staff members could not validate this allegation. (S1-S2) acknowledged since April 22, 2023, there have been some issues with the water pressure due to one of the boilers that operates by gas not operating correctly. (S1) notified Community Care Licensing (CCL) by submitting an incident report on April 23, 2025. (S1) provided a subsequent report to (CCL) on April 26, 2025, written notification to Residents and Families of Vista Del Mar Senior Living of Hot Water Service Disruption for the first and second floors. In the notice that it described, the HVAC contractor and Southern California Gas have been working to identify and resolve problems with the facility’s boiler system. The notice offered temporary accommodations with vacant rooms and common area shower rooms for residents affected by this problem. (S2) stated that all rooms have access to hot water because there is still one operational boiler. This boiler effectively transfers heat to the water by passing it through a pipe within the heated gas chamber. Consequently, while the water may take slightly longer to heat up, it remains universally available in every room. Utilizing two separate boilers enables a quicker heat transfer process that residents recognize. Staff member #3 (S3) stated that (S3) does not recall discussing the hot water issues with residents. Additionally, (S3) indicated that no residents have reported any concerns related to this matter. On May 1, 2025, between 10:35 AM and 12:00 PM, the Department interviewed resident members identified as Resident #1 through Resident #10 (R1-R10). Ten (10) out of the ten (10) resident members could not corroborate this allegation. (R1-R10) have access to running hot water in their rooms. Five (5) out of the ten (10) residents acknowledged receipt of the written notification regarding alternative amenities. (Evaluation Report continues LIC 9099-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 On May 1, 2025, between 1:30 PM and 2:30 PM, the Department conducted inspections of rooms #105, #117, #235, #236, #237, #238, and #239, as well as the kitchen and public restrooms. During the inspection, heated water was available, with temperatures ranging from 105.1°F to 118.0°F, which complies with Title 22 Regulations. Additionally, the Department observed the HVAC technician servicing the boiler systems. The Department also reviewed written communication reports dated April 23, 2025, and April 26, 2025, which indicated that the facility is taking proactive measures to address the boiler system issue. Based on the information gathered, there is not enough evidence to support the allegation mentioned above. Allegation #2: Staff does not keep resident’s room free from pests. The staff allegedly neglected to ensure that the residents were free from pests. Three cockroaches were reportedly found in a resident's room. Although a staff member was notified about the issue, no action has been taken to address it, and no further details have been provided. On May 1, 2025, between 9:30 AM and 10:30 AM, the Department interviewed staff members identified as Staff #1 through Staff #5 (S1-S5). Five (5) out of the (5) staff members expressed no pest activity in the facility, including resident’s rooms. (S1-S2) emphasizes its commitment to ensuring the safety and well-being of residents by implementing effective, environmentally friendly pest management measures. Their proactive approach protects their residents and promotes a healthier living environment for everyone. The facility has an active Service Agreement with a reputable pest control company that performs weekly routine pest control services. (S2) stated that these scheduled services are done every Tuesday and will treat 10 rooms and common areas weekly. Staff member #3 (S3), referenced in this complaint, indicated that (S3) do not remember conversing with residents regarding pest control issues. On May 1, 2025, between 10:35 AM and 12:00 PM, the Department interviewed resident members identified as Resident #1 through Resident #10 (R1-R10). Ten (10) out of the ten (10) resident members could not validate this allegation. All residents from (R1-R10) have stated that they have not encountered any pests within their rooms or in the facility's common areas. Additionally, they have observed pest control professionals actively performing treatments throughout the premises, ensuring a safe and pest-free environment for everyone. (Evaluation Report continues LIC 9099-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 On May 1, 2025, between 1:30 PM and 2:30 PM, the Department conducted inspections of rooms #105, #117, #235, #236, #237, #238, and #239, as well as the kitchen, activity rooms, and dining room. Upon inspection, no signs of pest activity were present in the area. The Department also reviewed a Dewey Pest Control Service Agreement dated December 12, 2024, which provided valid proof of an annual service contract. This contract indicated that ten units of service were performed monthly, totaling 40 treatments per month. Additionally, a review of the Dewey Pest Control Service Log, covering the period from April 1, 2025, to April 29, 2025, confirmed that treatment services are being performed weekly. Based on the information gathered, there is not enough evidence to support the allegation mentioned above. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. While the allegations may be valid or have occurred, there is insufficient evidence to establish whether the alleged violations took place or did not. Therefore, the allegations are determined Unsubstantiated . An exit interview with Executive Director, Suzette Johnson and reports were provided.

Continued LIC9099-C page 2 Investigation revealed the following: On 04/21/2025, it was alleged that a resident was unable to eat the food served due to the resident's dietary restrictions. It was reported that the facility maintains a record of residents’ special dietary needs; however, it does not consistently follow them. It was also reported that the facility does not have a dietitian. The facility does not provide substitutions that residents can eat on a regular basis. Although the facility uses meal menu slips for residents who are unable to make their way to the dining hall, staff have at times forgotten to pick up residents’ meal slips from their rooms, resulting in residents not receiving meals on multiple occasions. It was reported that on 04/20/2025 at 9:30 p.m., a male resident with dementia entered a resident’s room without permission while the resident was sleeping. The resident woke up, yelled at the male resident to leave, and pressed the pendant for assistance. The staff responded within three minutes and removed the male resident. Allegation: Staff do not ensure residents' dietary care plan is being followed. On 04/28/2025, the Department interviewed staff members 1-2 (S1-S2) and residents 1-10 (R1-R10) regarding the allegation. Staff members (2 out of 2) and 9 out of 10 residents stated staff does ensure residents' dietary care plans are being followed. They confirmed that staff consistently adhere to the physician-prescribed dietary menu, and residents are served well-balanced, nutritious meals according to the doctors' orders. S1-S2 and R2-R10 stated that the facility does have a dietitian. R1 stated that staff do not ensure residents' dietary care plan is being followed. S1-S2 and R2-R10 all denied the allegation. Allegation: Staff do not ensure the resident is provided with breakfast, lunch, and dinner each day. On 04/28/2025, the Department interviewed staff members 1-2 (S1-S2) and residents 1-10 (R1-R10) regarding the allegation. Staff members (2 out of 2 ) and 9 out of 10 residents stated staff does ensure the residents are provided with breakfast, lunch, dinner, and snacks. Residents confirmed they receive three meals per day, alternative food choices are offered. The facility provides a diverse range of food options, and if a resident requests a second serving, staff accommodates the request. R2-R10 stated they receive plenty of food to eat, and if they don't want to dine in the dining lounge, they can complete a tray service request. Staff will collect the request slip and deliver the meal to the resident's room. R1 stated that staff do not ensure residents are provided with breakfast, lunch, and dinner each day. S1-S2 and R2-R10 all denied the allegation. See continued LIC9099-C 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 Continued LIC9099-C page 3 Allegation: Staff do not ensure adequate care and supervision is provided to residents On 04/28/2025, between 10:00 a.m. and 11:30 a.m., the Department interviewed two staff members #1 and #2 (S1-S2), regarding the allegation. S2 stated that a resident reported another resident had entered their room; however, there were no witnesses to the incident, and a review of the facility’s surveillance cameras did not reveal any unauthorized entry. Maintenance checked the resident's door and confirmed it was in operable condition. S1 and S2 explained that care staff conduct Wellness checks on residents every two hours. All residents have pendants and call buttons to alert staff if they need assistance. Staff confirmed that no unauthorized individuals were observed entering residents’ rooms. S1 and S2 stated residents’ doors remain locked, and each resident has a personal key to their own room. S1-S2 states the facility currently has about 93 staff members employed and is fully staffed, and that residents are receiving appropriate care, supervision, and assistance with their daily needs. Both interviewed staff (2 out of 2) confirmed the facility is sufficiently staffed and denied the allegation. On April 28, 2025, between 11:45 a.m. and 12:00 p.m., the Department reviewed the facility’s Personnel Report (LIC 500), which listed the following staff positions: Executive Director; Human Services Director; Vice President of Operations; Business Office Manager; Human Resources Director; Resident Care Director; ALW Coordinator; 4 Licensed Vocational Nurses (LVNs); 2 Community Liaisons; 2 Maintenance Staff; 4 Cooks; 5 Kitchen Staff; 4 Food Servers; 2 Dishwashers; 6 Dietary Aides; 9 Medication Technicians; 7 Memory Care Caregivers; 1 Memory Care Activity Director; 2 Activities Assistants; 25 Caregivers; 7 Housekeepers; 4 Receptionists; and 1 Driver a total number of employees listed: 93, confirmed the facility is adequately staffed. On April 28, 2025, between 12:00 p.m. and 2:30 p.m., on the same day, the Department conducted interviews with ten residents #1-#10 (R1–R10) regarding the allegation of inadequate care and supervision. 9 out of 10 residents stated that the facility is adequately staffed and confirmed they are receiving the necessary care and supervision. 9 out of 10 also stated that staff are consistently present every shift. 1 out of 10 residents expressed concern about staffing and did not feel care and supervision were adequate. 9 out of 10 residents reported that they were happy living at the facility and had no problems or complaints. The majority of residents (9 out of 10) denied the allegation and stated that their daily needs were being met. Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegations. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed unsubstantiated. There were no deficiencies cited. An exit interview was conducted.

Medication Administration Records (Dated: 10/01/2024-12/31/2024), and current Physician’s Orders (Dated: 12/31/2024) were also obtained from the facility. This complaint was referred to the California Department of Social Services Investigation Bureau for investigation and was assigned to Investigation Bureau Investigator, Olivia Spindola. As a part of the investigation, Investigator Spindola subpoenaed copies of College Medical Center medical records for resident (R1) which included: progress notes, physicians orders, psychological exam, lab results, and medication list. Additionally, the investigator conducted interviews with staff (S1-S4), witness (W1), and residents (R1-R3). The investigation revealed the following: Allegation-Resident had unknown exposure to fentanyl while in care. It is alleged that resident had exposure to an illegal drug while living at the facility. On 12/18/24 the resident was admitted to College Medical Center where they tested positive for the illegal drug Fentanyl. On 01/15/25, from 11:30am-1:00pm, the department interviewed staff (S1-S3); On 2/11/25, from 11:00am-3:30pm, the department interviewed residents (R1-R3) and staff (S4), and on 3/18/25, from 4:00pm-4:30pm, the department interviewed witness (W1) about the complaint allegation. 4 of 4 staff denied the allegation that the Resident had unknown exposure to fentanyl while in care. Staff denied knowing how the resident tested positive for the illegal drug. Staff also stated the resident resides in a locked area and cannot leave without supervision or assistance from staff. They further deny that the resident had access to illegal narcotics inside the facility or that anyone would provide the resident with Fentanyl. The department interviewed residents (R1-R3) about the allegation and 2 of 3 residents denied the allegation, while one resident was unable to participate in the investigation due to poor health. The residents that were interviewed stated that they have not witnessed any illegal drug use in the facility and was not aware of anyone providing illegal narcotics to residents. The department reviewed medical records from College Medical Center for R1 and observed that (R1) tested positive for Fentanyl on 12/18/2024, and 12/31/2024, when hospitalized at College Medical Center (CMC). The CMC records revealed that (R1) was hospitalized on an involuntary psychiatric hold for reported increased aggression and combativeness. Although the medical records indicated (R1) tested positive for Fentanyl during both hospitalizations, the department did not uncover any evidence or obtained any witness statements indicating that (R1) had access to Fentanyl or any other illegal narcotics, as (R1) resides in the Memory Care Unit of the facility, which is a locked area. The CMC records also indicated that (R1) takes several psychotropic medications to treat schizoaffective disorder, which included Olanzapine, Risperidone, Lorazepam, Quetiapine, and Trazadone. According to www.pubmed.ncbi.nlm.nih.gov , antibiotics, analgesics, and antidepressants medications such as Quetiapine and Risperdal are known to give false-positive for Fentanyl in laboratory testing. The nurse assistant (W1) stated that Quetiapine and Risperidone are drugs known to give false-positive for Fentanyl. Page 2 of 3 LIC9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Based on records reviewed and interviews conducted, there is insufficient evidence to support the allegation that the Resident had unknown exposure to fentanyl while in care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated . No citations were issued for this complaint. An exit interview was conducted, and a hard copy of this Complaint Investigation Report was provided to Suzette Johnson, Administrator . Page 3 of 3 LIC9099-C

On 02/20/25 from 10am-11am LPA conducted interviews with (S1-S4) regarding the allegation above, 4 of 4 staff interviewed denied the allegation above. Per 1 of 4 staff interviewed, the facility works with a registry/agency if there is a shift that needs to be covered. On 02/20/25 from 11:15 am to 12:45pm LPA conducted interviews with R1-R6, 4 of 6 residents denied the allegation above, 2 of 6 residents interviewed reported experiencing an un-witnessed falls in the past. 6 of 6 residents reported feeling safe when assisted by staff. On 02/20/25 LPA conducted a review of memory care staff time cards and schedules, LPA observed that there is a total of 42 memory care residents which are split into 4 groups daily. LPA observed memory care to have 6 staff for the morning, 4 staff in the evening shifts, and 2 staff for NOC shift. 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 interviewed conducted, and a copy of this report was provided.

The details of the complaint alleged that the facility does not provide the required personal accommodations to residents. It is alleged that residents are not provided a chair in their room per Title 22 regulations. On 02/05/25, from 1:00pm-3:00pm, the department interviewed staff (S1-S4) and residents (R1-R10) regarding the allegation. 4 of 4 staff denied the allegation that the Facility staff did not provide resident with a bedroom chair. All staff (S1-S4) interviewed stated that the facility does provide the required items per Title 22 regulations. S1-S4 stated that when a resident moves in they are provided with a bed, nightstand, chair, lamp, and dresser. Staff also stated that sometimes a resident brings their own furniture, but the option is still available to them if they need it. S1 stated that one resident recently asked if they could provide them with a gamer chair in their room. S1 stated no because the facility does not offer that kind of chair but could provide the resident with a standard chair. S1 stated the resident was not happy and wanted the gamer chair. The department interviewed residents (R1-R10) about the allegation and 9 of 10 residents that were interviewed denied the allegation that Facility staff did not provide resident with a bedroom chair. The majority of the residents (9 of 10) stated that they did not have a problem with the facility. 4 of 9 residents stated that they brought their own furnishings with them when they moved in and 5 of 9 residents stated that the facility did provide them with a chair and the other furnishings for their bedroom. The department toured the facility and observed bedrooms # 109, 116, 118, 137, 138, 242, 245, 271A, 271B and 293; and all rooms had the required furnishings per Title 22 regulations. Based on interviews conducted, there is insufficient evidence to support the allegation that the Facility staff did not provide resident with a bedroom chair. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated . No citations were issued on this complaint visit. An exit interview was conducted, and a hard copy of this Complaint Investigation Report was provided to Suzette Johnson, Executive Director.

On 01/31/25 LPA obtained copies of progress notes where it is Documented that physicians have been contacted regarding medication refusals. The investigation revealed the following: Allegation: Staff do not ensure medication is stored in originally received container. It is being alleged that staff are preparing medications several days in advance. On 01/23/25 and 01/31/25 LPA conducted interviews with ED, and S1-S4 regarding the allegation above, 5 of 5 staff denied the allegation above. On 01/23/25 and 01/31/25 LPA conducted interviews with R1-R10, 9 of 10 residents interviewed denied the allegation above and reported meds are prepared in front of them by med room staff, 1 of 10 residents interviewed reported resident is provided with meds already in a med cup. On 01/23/25 LPA conducted a tour of the medication room and observed medications to be in their originally bottle or bubble packs. Allegation: Staff do not ensure the facility is free of insects. It is being alleged that there are roaches in the medication room. On 01/23/25 and 01/31/25 LPA conducted interviews with ED, and S1-S4 regarding the allegation above, 3 of 5 staff interviewed reported pet have been observed in the past, it was reported, and the med room was treated by pest control. 2 of 5 staff interviewed denied the allegation above. On 01/23/25 and 01/31/25 LPA conducted interviews with R1-R10, 6 of 10 residents interviewed denied the allegation above, 4 residents interviewed reported pest has been observed in the past however, it was reported to maintenance treatment has been provided. On 01/23/25 LPA conducted a tour of the medication room and did not observe any signs of pest, and med room was clean. On 01/31/25 LPA reviewed the p est control reports for December 2024 and January 2025, it is documented that the pest control company is coming out every week to treat rooms where pet have been reported as well as common areas. Allegation: Staff mismanaged residents' medication. It is being alleged that staff are being instructed to give a resident a medication that belongs to another resident because the resident was out of a particular medication. On 01/23/25 and 01/31/25 LPA conducted interviews with ED, and S1-S4 regarding the allegation above, 5 of 5 staff interviewed denied the allegation above. 4 of 5 staff interviewed reported there is an over flow of medications located in the med room to ensure a resident does not run out of medications. 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 01/23/25 and 01/31/25 LPA conducted interviews with R1-R10, 9 of 10 residents denied the allegation above and reported they have not run out of medications. 1 of 10 residents interviewed reported running out of medications from Kaiser due to a payment mis-communication with family. On 01/23/25 LPA observed there is an over flow of medications for residents stored in med room cabinet. Over flow was observed to be organized and labeled with residents name. LPA reviewed in-service held and attended by all medroom staff dated 09/25/24 and 10/16/24 for ordering and documenting medications. Allegation: Staff are falsifying residents' medication administration record (MAR). It is being alleged that med techs are entering meds as given even when they don't administer it. On 01/23/25 and 01/31/25 LPA conducted interviews with ED, and S1-S4 regarding the allegation above, 5 of 5 staff interviewed denied the allegation above. 4 of 5 staff interviewed reported MARs are documented in real time. On 01/23/25 LPA conducted a medication review for R1-R6, LPA did not observe any discrepancies on the MAR. 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 conducted, and a copy of this report was provided.

The investigation revealed the following: Allegation #1-Staff did not seek medical attention for resident in a timely manner. The details of the complaint alleged that the resident (R1) had a fall at the facility two days prior before (R1) was taken to the hospital for head trauma and dizziness; and no one sought medical attention for the resident. On 12/19/24, from 12:00pm-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R10) regarding the allegation. 4 of 4 staff denied the allegation that the Staff did not seek medical attention for resident in a timely manner. All staff (S1-S4) interviewed stated that the facility had no knowledge of a fall and that they informed the family member on 12/14/24 when it was discovered that R1 had dried blood on the left side of R1s face and shaved hair in spots on the left side of R1s head as well. Staff stated that they checked R1s room for evidence of a fall and did not notice anything out of the ordinary. Staff also stated that they checked R1s room, floors, pillows, bathroom, furniture, and clothing for blood stains and could not find any. S2 stated that they observed the dried blood on R1 and asked R1 if R1 was in pain, R1 said no. S2 then asked who shaved your head like that, did you or anyone else do that, R1 said R1 was not sure. S2 then stated that they alerted management and management called the family member the same day that it was noticed on 12/14/24, and the family came and took R1 to urgent care. Staff also stated that they had no reports that R1 had fallen and when asked if R1 had fallen, R1 said no. Staff (S3) stated that S3 saw R1 on 12/13/24 and R1 looked fine and had no issues. But that on 12/14/24 they noticed a problem. S1 stated that the resident had shavers in R1s room, S1 stated that they packed them up and gave them to R1s family member. The Department reviewed the Unusual Incident/Injury Report (Dated: 12/19/24) that was sent to the department noting that R1 was found with dry blood and part of the top of R1s left head shaved in spots. The department also reviewed the After Visit Summary (Dated: 12/14/2024) that noted R1 had dry blood on left forehead and was unclear of etiology. The report also stated that R1 had no acute intracranial abnormalities. R1 was evaluated and returned to the facility. The department interviewed residents (R1-R10) about the allegation and 9 of 10 residents that were interviewed denied the allegation that Staff did not seek medical attention for resident in a timely manner. The majority of the residents interviewed (9 of 10) stated that they have not had any problems with staff seeking medical attention when they need it. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff did not seek medical attention for resident in a timely manner. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated . Complaint Investigation Report Continued on LIC9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation #2- Staff did not keep resident's authorized person informed about incidents involving the resident. The details of the complaint alleged that the staff did not inform the resident’s authorized person about the incident that occurred at the facility. On 12/19/24, from 12:00pm-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R10) regarding the allegation. 4 of 4 staff denied the allegation that the Staff did not keep resident's authorized person informed about incidents involving the resident. All staff (S1-S4) interviewed stated that the family member was notified on 12/14/24 when they noticed that the resident had dried blood and hair that was shaved in spots on the left side of R1s head. Staff (S4) stated that the family member was notified that day and that S4 sent the family member a picture of R1 that showed the dry blood and shaved hair. S4 also stated the family responded by coming to the facility on that same day and as a precaution took R1 to urgent care. All staff (S1-S4) corroborated that the family member was made aware of the incident with R1. The department reviewed the Resident Incident Charting Notes (Dated: 12/14/2024) that showed the incident was logged and the family was notified. The department also received an incident report (Dated: 12/19/24) that was sent to the Department of Social Services, Community Care Licensing Division, detailing the incident. The department interviewed residents (R1-R10) about the allegation and 9 of 10 residents that were interviewed denied the allegation that Staff did not keep resident's authorized person informed about incidents involving the resident. The majority of the residents (9 of 10) interviewed stated that the staff does inform their authorized person when they have incidents at the facility. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff did not keep resident's authorized person informed about incidents involving the resident. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated . No deficiencies were cited. An exit interview was conducted with Suzette Johnson, Executive Director, and a hard copy of this Complaint Investigation Report was provided.

Investigation Revealed the Following: Allegation: Allegations: Staff do not assist resident with obtaining medical care. The details of the complaint alleged that facility staff is not assisting (R#1) with their medical appointments. During the records review, LPA Iniguez reviewed (R#1)’s medical file; LPA observed that (R#1) has Kaiser as their medical provider. A letter dated 12/9/24 from (R#1)’s doctor states that (R#1) requested to manage their own medications and medical care; the doctor wrote that they could manage their medications and medical care. During an Interview with the Administrator (A#1), she stated that in the case of (R#1), they call Kaiser to have them pick them up, but we can always provide transportation for them if they need it. During interviews with residents (R#1-R#14), (8) out of (14) stated that the family takes them to their medical appointments, (1) out of (14) stated that they go on their own, (5) out of (14) state that the used the facility transportation and (1) out of (14) stated that their doctor comes at the facility to see them. In addition, (13) out of (14) residents stated that they feel the facility will assist them if they require transportation to their medical appointments. During interviews with facility staff (S#1-S#9), (9) out (9) stated that the facility provides and assists the residents in care with transportation. Evaluation Report continues LIC 9099-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 Allegation: Staff do not allow resident to choose care provider. The details of the complaint alleged that facility administrator is forcing (R#1) to choose in-house doctor. During the records review, LPA Iniguez examined (R#1)’s medical file and noted that (R#1) is enrolled with Kaiser as their medical provider. A letter dated December 9, 2024, from (R#1)’s doctor confirms that (R#1) requested to manage their own medications and medical care and has an active membership on file. During an interview with the administrator (A#1), she stated that she had never forced (R#1) or other residents in care to change their primary care physicians to choose our in-house doctor. During interviews with residents (R#1-R#14), (13) out of (14) stated that the administrator has never forced them to change their primary care physician for an in-house doctor. During interviews with facility staff (S#1-S#9), (9) out (9) stated that they had never heard that the administrator was forcing the residents in care to change their doctors for the facility doctor. Evaluation Report continues LIC 9099-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 Allegation: Staff did not safeguard resident's personal belongings. The details of the complaint alleged that facility staff is not safeguarding (R#1)’s personal belongings. During the records review, LPA Iniguez reviewed (R#1)’s admission file. LPA observed that (R#1) declined to list their personal belongings on the Client/Resident Personal Property and Valuables or LIC 621 form, which is dated 3/14/2024 and signed by (R#1). In addition, LPA reviewed (R#2-R#4)’s admission files, and everyone has an LIC 621 form on file. During an Interview with the Administrator (A#1), she stated that the facility staff safeguard the personal belongings of (R#1) and the residents in care. The facility staff never takes anything from the resident’s room, including money. In addition, (A#1) stated that she had never heard about a resident sleeping in their wheelchair the whole night because their bed was broken. During interviews with residents (R#1-R#14), (13) out of (14) stated that they have an inventory list on file and that the facility staff is not taking their personal belongings, including money. In addition, (13) out of (14) residents stated that they had never heard of another resident sleeping in their wheelchair the whole night because their bed was broken. During interviews with staff (S#1-S#9), (9) out (9) stated that they do not take the personal belongings of (R#1) or other residents in care, including money. In addition, (9) out of (9) facility staff never heard about a resident sleeping in their wheelchair the whole night because their bed was broken. Evaluation Report continues LIC 9099-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 During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Suzette S. Johnson / Executive Director.

12/10/24 LPA Villegas conducted case management deficiencies visit in order to issue a citation observed during complaint investigation, control number 11-AS-20241209092305. LPA met with Executive Director Suzette Johnson as the purpose of the visit was explained. The facility failed to report an incident that occurred on 11/30/24 where resident #1 (R1) sustained a fall at the facility. Based on observations LPA Villegas did observe documentation on nurse notes that R1 sustain a fall on 12/01/24. On 12/10/24 ED confirmed that incident occurred on 12/01/24 and confirmed an incident report was not submitted to CCLD within (7) days. The licensee is being cited with Title 22 Reporting Requirements 87211(a)(1)(B) Based on interviews, and record reviews the licensee violated the California Code Regulations (CCR) of Title 22, Division 6, Chapter 8 by not reporting the incident to Community Care Licensing. Exit interview conducted with Executive Director Suzette Johnson, appeal rights explained, and a copy of this report was provided.

The investigation revealed the following: Allegation: Staff do not ensure the facility is free from pests It is being alleged that there is a mice, rats, and roach problem at the facility. On 11/20/24 between 11:30 am-12:15pm LPA conducted interviews with S1-S4, 4 of 4 staff interviewed denied the allegation above and reported bedrooms are sprayed by Terminex pest control when pest are reported by residents. 4 of 4 staff also reported rooms are being monitored for pest when cleaning is being conducted. On 11/20/24 between 9:30 am-11:30am LPA conducted interviews with residents R1-R7, 3 of 7 residents interviewed denied the allegation above, 1 of 7 residents refused interview, 3 of 7 residents interviewed confirmed the allegation and reported traps are placed and the bedroom gets sprayed when reported. On 11/22/24 at 9am LPA conducted interview with (S5),1 of 5 staff interviewed denied the allegation above and reported pest control visits the facility regularly to spray. On 11/22/24 between 9:15am- 11:30am LPA conducted interviews with R8-R10 regarding the allegation above, 3 of 3 residents interviewed denied the allegation above. On 11/20/24 while touring the inside and outside of the facility, LPA did not observed any pest activity. On 11/22/24 LPA conducted a a review of Terminex service reports and observed that the facility is being treated weekly. Allegation: Staff do not ensure the facility is clean and sanitary. It is being alleged that the facility is dirty and that the staff don't clean the rooms nor the bathrooms well. On 11/20/24 between 11:30 am-12:15pm LPA conducted interviews with S1-S4, 4 of 4 staff interviewed denied the allegation above and reported bedrooms along with the rest of the facility are cleaned daily and bedrooms are deep cleaned 1 time per week. Per 4 of 4 staff, some bedrooms require cleaning 2-3 times a week. On 11/20/24 between 9:30 am-11:30am LPA conducted interviews with residents R1-R7, 5 of 7 residents interviewed denied the allegation above, 1 of 7 residents refused interview, and 1 of 7 residents interviewed confirmed the allegation above, and stated the bedroom is cleaned once a week. On 11/22/24 at 9am LPA conducted interview with (S5),1 of 5 staff interviewed denied the allegation above and reported bedrooms and all common areas are cleaned daily and bedrooms are deep cleaned 1 time per week. On 11/22/24 between 9:15am- 11:30am LPA conducted interviews with R8-R10 regarding the allegation above, 3 of 3 residents interviewed denied the allegation above. On 11/21/24 while conducting tour of the facility LPA observed both floors being cleaned by the staff; trash was being removed and housekeepers were moping the floors. On 11/22/24 LPA reviewed the housekeeping schedule and observed that rooms are cleaned daily and deep cleaned once a week. 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: Staff do not ensure resident has hot water It is being alleged that R1's bathroom sink has no hot water and get's lukewarm at best. On 11/20/24 between 11:30am-12:15pm LPA conducted interviews with S1-S4, 4 of 4 staff interviewed denied the allegation above. 1 of 4 staff interviewed stated residents have asked for the water temperature to be higher however it was explained that the facility has to be incompliance with water temperatures and hotter water temperatures may be harmful to other residents. On 11/20/24 between 9:30am-11:30am LPA conducted interviews with residents R1-R7, 5 of 7 residents denied the allegation above, 1 of 7 residents refused the interview, 1 of 7 residents confirmed the allegation and reported the water temperature was turned down, the water temperature is too low and not to the residents liking. On 11/20/24 LPA checked the water temperatures of 4 random rooms and the following was observed: room # 135 water temp 111.7 F, room # 137 water temp 113.6F, room # 293 water temp is 114.2 and room 227 water temp is 116.2. On 11/22/24 at 9am LPA conducted interview with S5, 1 of 5 staff interviewed denied the allegation above. On 11/22/24 between 9:15am- 11:30am LPA conducted interviews with R8-R10 regarding the allegation above, 3 of 3 residents interviewed denied the allegation above. On 11/22/24 LPA conducted review of the water temperature log for the months of January 2024 -November 2024, LPA observed that water temperatures are checked regularly to ensure compliance. 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 conducted with Executive Director Suzette Johnson, and a copy of this report was provided.

The investigation revealed the following: Allegation: Staff is serving food that is not of good quality. It is alleged that facility is not serving food of good quality. On 10/17/24 between 10:00am- 11:30 am LPA conducted interview with ED regarding the allegation above, ED denied the allegation above and reported there are monthly meetings held to hear the needs of the residents. On 10/17/24 between 10:00am- 11:30am LPA conducted interviews with S1-S5 regarding the allegation above, 5 of 5 staff interviewed denied the allegation above and reported residents have not complained of the food quality. On 10/17/2024 LPA toured the inside of the facility, during the tour LPA observed the kitchen, dining area and the facility’s food supply. LPA observed residents eating in the dining area and LPA did not observe food not of good quality being served. On 10/17/24 from 9:30am-10 am LPA conducted interview with R1, and on 10/24/2024 between 9:30am- 11:45am LPA conducted interviews with R2-R10 . 8 of 10 residents interviewed denied the allegation above and reported having no concerns regrading the quality of food being served, 2 of 10 resident interviewed stated the food can be better. On 10/24/24 LPA observed residents having lunch in the dining area and did not observe food not of good quality being served. Allegation: Foods are not properly labeled It is being alleged that drinks served are not labeled sugar or sugar free. On 10/17/24 between 10:00am- 11:30 am LPA conducted interview with ED regarding the allegation above, ED denied the allegation above and reported kitchen manager oversees the labeling in the kitchen. On 10/17/24 between 10:00am- 11:30am LPA conducted interviews with S1-S5 regarding the allegation above, 5 of 5 staff interviewed denied the allegation above. On 10/17/24 LPA conducted a tour of the facility kitchen as well as observed lunch seatings, LPA observed sugar free items to be separated and labeled in the pantry. LPA also observed the juice which was placed in a beverage pitcher to be labeled as regular/sugar and or sugar free. On 10/17/24 from 9:30am-10 am LPA conducted interview with R1, and on 10/24/2024 between 9:30am- 11:45am LPA conducted interviews with R2-R10. 5 of 10 residents interviewed denied the allegation above, 2 of 10 residents interviewed were unsure of labeling, 2 of 10 residents interviewed reported drinks are sometimes labeled, and 1 of 10 residents interviewed confirmed the allegation and reported juices are not labeled when served. 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 conducted with Executive Director Suzette Johnson, and a copy of this report was provided.

Allegation: Staff do not answer resident’s calls for assistance. The complaint allegation alleges that the facility staff do not always answer calls for help or assistance. During the facility inspection, the Department tested resident call buttons in rooms 111, 205, 242, and 316. The Department timed how long it took for a caregiver to answer the call for assistance and the following times were recorded 6 minutes, 5 minutes, 6 minutes, and 8 minutes. During interviews with Staff S1 – S8, were asked how long it takes to respond to a resident’s call for assistance, eight (8) out of eight (8) stated they respond to residents calls for assistance in less than 10 minutes. During interviews with Residents R1-R11, were asked how long it takes staff to respond to their calls for assistance, seven (7) out of eleven (11) stated the staff come right away when called. Additionally, Residents R1-R11 were asked if there was a time they called for assistance and staff did not respond or come, four (4) out of eleven (11) stated there has been a time when they called for assistance and staff did not come to assist. Additionally, Residents R1, R3, R4, and R6, were asked what time of day the incident occurred, four (4) out of four (4) stated it happened during the evening and nights. Allegation: Staff do not ensure facility is free from pests. The complaint allegation alleges roaches were observed in the dining room and residents’ bed has bed bugs. During the facility inspection, the Department did not observe insects or any traces of insects. The facility and rooms inspected were observed clean and sanitary. 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 During Record review, the Department received and reviewed receipts from Terminix pest control company dated 07/03/24 through 09/25/24. The Department observed Terminix has come out weekly to provide services. During interviews with Staff S1-S8, were asked if they have recently observed any insects or pests inside the facility, six (6) out of eight (8) stated they have not seen any insects inside the facility. Two (2) out of eight (8) stated they see cockroaches off and on but not since June. Additionally, Staff were asked if there is a pest control company that comes and provides services, eight (8) out of eight (8) stated Terminix comes out on a weekly basis to provide services. During interviews with Residents R1- R11, were asked if they have recently observed any insects or pests inside the facility, five (5) out of eleven (11) stated they have observed cockroaches inside the facility. Additionally, they stated if they see them inside the facility is on it and takes care of it quickly. Additionally, Residents R1-R11, were asked if there is a company that comes out to treat for the cockroaches, eleven (11) out of eleven (11), stated there is a company that comes out regularly. Allegation: Staff do not maintain facility in good repair. The complaint allegation alleges that their air conditioning and refrigerator in their room is not working properly. During the facility inspection, the Department observed the facility to be in good repair. The Department checked residents air conditioning and refrigerator in rooms visited and observed them to be working. During record review, the Department received and reviewed work orders from 09/14/24 through 10/23/24. 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 During interviews with Staff S1 – S8, were asked what the process and procedure is if a resident reports something not working in their room is, eight (8) out of eight (8) stated once an issue is reported a work order is created, maintenance goes right away to check on the issue and they decide what is needed for a repair and once parts are ordered and received the issue is fixed. If the issue can be fixed right away, they fix it then. During interviews with Residents R1- R11, were asked if there was anything in the facility or in their room that is not working properly, ten (10) out of eleven (eleven) stated everything in their room is working properly and if something needs fixed, they come right away to fix it. During an interview with R1, they stated their refrigerator keeps freezing up and needs defrosted then sometimes takes a while to get cold. During the facility inspection, the Department observed R1’s refrigerator was working properly . During the course of the investigation, LPA was unable to find evidence to support the allegations. Although the allegations may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated . An exit interview was conducted with Executive Director, Suzette Johnson, and a copy of this report was provided.

due to an end stage illness. All Hospice agencies contacted and conservator where unaware of any staff neglect. Based upon this information gathered LPA finds that 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 Regarding Allegation : Staff did not prevent a resident from causing self harm It was alleged that facility staff did not prevent a resident from causing self harm by cutting her wrist. During this visit LPA reviewed incident report of this incident dated 5/30/2024. LPA interviewed Staff #1 and Staff #2 which are both Med room staff who observed R#7 on day of incident. Incident report and staff interviews were consistent with incident: R#7 brought scissors to the Medroom and asked the staff to keep her scissors for her. Staff #1 asked R#7 why did she want them to hold the scissors for her and R#7 stated It would be safer for her. Staff took the scissors. Staff insist that R#7 did not seem distressed and acted normal. Later R#7 sustained a self cut to her wrist. LPA Day interviewed Administrator Suzette Johnson who explained the facility procedures of when a resident presumes to be distress or unusual behavior, that resident is put on a hourly watch. After R#7 brought the scissors to the Medroom S#1 alerted Administrator and was put on an alert. However R#7 cut herself within minutes of leaving the Medroom. LPA reviewed Physician report and Needs and Service Plan of R#7 which did not indicate any history of suicidal tendencies nor a history of cutting herself. During this visit LPA was unable to interview R#7 due to she has moved and whereabouts are unknown. Based on the information gathered and the interviews conducted LPA Day finds that the Staff had no knowledge of R#7 intent to harm herself , therefore could not prevent it. There is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED An Exit interview was conducted with Suzette Johnson Administrator and Sidonia Cordis, Resident Care Director and a copy of this report was provided

On 09/11/24, Licensing Program Analyst's (LPA's) Villegas and Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA's met with Executive Director Suzette Johnson as the purpose of today’s visit was explained. The facility is licensed to serve 300 non-ambulatory elderly adults 60 and over of which 10 may be bedridden, there is an approved hospice waiver for 50 residents. The facility has a dementia wing w/ delayed egress. Executive Director was provided with upcoming fees info and pin, fees due on 10/11/24. The facility has an active liability insurance with expiration date of 10/26/24. The facility is a 3-story structure located in a residential neighborhood and consists of the following: 278 bedrooms, 4 common bathrooms, multimedia rooms, commercial kitchen, activity room, large dining room, medication room, a large outside patio, laundry room, and administrative offices. LPA’s conducted a records review of 8 staff records, 10 resident records, and 10 medication administration records, records were maintained accordingly with no discrepancies. LPAs observed medications were centrally stored and properly locked. The last fire and disaster drill was conducted on 06/19/24, fire extinguishers fully charged and observed throughout the facility, carbon monoxide detectors, smoke detectors and auditory signals are operational. Landline and internet service was observed. During facility tour 10 Resident bedrooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Bathroom toilets and water faucets worked properly, showers were free of mold/mildew, and there are sufficient toiletries accessible to residents. Water temperature properly measured between 105-120 F., there was a comfortable temperature maintained throughout the facility. LPAs conducted tour of commercial kitchen, LPAs observed an adequate supply of perishable and non-perishable food. Toxins and knifes were observed to be inaccessible to residents. Exits/ Walkways around the facility were free of debris and hazards. Exit interview conducted with Executive Director Suzette Johnson, and copy of this report was provided.