Cadence Millbrae

On 08/27/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced annual inspection visit. LPA met with the executive director Holly Suiter and explained the purpose of today's visit. There are currently 136 residents in assisted living and 21 in memory care. This is a multi-level facility approved for all residents allowed to be non-ambulatory, five bedridden, and a hospice clearance for 14 residents. This facility does have a secured memory care area. The physical plant was toured inside and outside of the facility to ensure the safety of the clients. LPA observed the facility kitchen which is clean and observed appliances are in good repair. Knives are stored and locked and secured in the kitchen. Perishable and non-perishable food supplies are observed as in place. Kitchen grade fire extinguisher is observed as in place and with an inspection date of 06/08/2024. First aid kit is observed as complete with required items as observed in medication room. Medications are observed to be locked in cabinets and medication cart in the medication room. LPA reviewed resident medications at random and observed them as current. LPA observed that there are multiple fire extinguishers in place on each floor with an inspection date of 07/07/2025 smoke detector, carbon monoxide detectors are observed in place through out the facility, and central heating and air conditioning. Laundry areas are also observed as fully operational. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Last emergency/disaster drill was conducted in May 2025. Water temperature was measured at 108F in resident rooms at random and 111F in a common bathroom. Cleaning supplies are observed to be inaccessible to residents in care. Resident rooms are observed at random. LPA observed two resident rooms and both appeared clean, free of odors, and contained all the required furniture per regulatory recommendations. Continued on next page... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Page 2 Resident linen supplies are observed as in place. LPA reviewed five staff files and five resident files during today's inspection and all files are observed as current. Staff are actively conducting training via Relias and it is observed as current. Administrator certificate is current expiring 01/14/2027. The following updated forms are requested to be submitted to CCLD by 09/03/2025 : • Copy of facility's liability insurance • LIC610E Emergency Disaster Plan • LIC500 Staff Schedule No citations issued. Report is reviewed with Holly and a copy is provided on this day.

On 11/08/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management - incident visit in response to an SOC 341 report received on 11/07/2024. LPA met with administrator Joan Newman and explained the purpose of today's visit. During today's visit LPA conducted interviews and collected pertinent documents regarding the resident. LPA also discussed the incident with the local long term care ombudsman assigned to this facility regarding the incident. Facility staff investigated the reported incident but could not come to any conclusions. The person in question as described by the resident, could not be a staff member as there are no staff matching the description of the supposed person. Male residents in the area also do not match the description provided. Facility does not have cameras in common areas of the facility. Per the facility the incident was reported to the hospice agency who then reported to the facility. As a precaution the facility has implemented a plan to assist the resident in order to prevent any issues in regards to males entering the resident's room. The facility has assigned no male staff to the resident, but if there is a male med-tech needs to visit the resident, they are to be accompanied a female care partner. The facility met with the family and they are aware and are working with the facility at this time. No further issues were discussed. No citations issued.

On 08/20/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced annual inspection visit. LPA met with the executive director Joan Newman and explained the purpose of today's visit. There are currently 91 residents in assisted living and 17 in memory care. LPA was allowed entry into the facility. This is a multi-level facility approved for all residents allowed to be non-ambulatory, five bedridden, and a hospice clearance for 14 residents. This facility does have a secured memory care area. The physical plant was toured inside and outside of the facility to ensure the safety of the clients. LPA observed the facility kitchen which is clean and observed appliances are in good repair. Knives are stored and locked and secured in the kitchen. Perishable and non-perishable food supplies are observed as in place. Kitchen grade fire extinguisher is observed as in place and with an inspection date of 06/08/2024. First aid kit is observed as complete with required items as observed in medication room. Medications are observed to be locked in cabinets and medication cart in the medication room. LPA reviewed resident medications at random and observed them as current. LPA observed that there are multiple fire extinguishers in place on each floor with an inspection date of 06/12/2024, smoke detector, carbon monoxide detectors are observed in place through out the facility, and central heating and air conditioning. Laundry areas are also observed as fully operational. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Last emergency/disaster drill was conducted on 08/07/2024. Water temperature was measured at 111F in resident rooms at random. Cleaning supplies are observed to be inaccessible to residents in care. Resident rooms are observed at random. LPA observed five resident rooms and all appeared clean, free of odors, and contained all the required furniture per regulatory recommendations. Continued on next page... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Page 2 Resident linen supplies are observed as in place. P&I monies are not handled by the facility. LPA reviewed four staff files and five resident files during today's inspection and all files are observed as current. Staff conducting via Relias and observed as current. Administrator certificate is current expiring 02/28/2025. The following updated forms are requested to be submitted to CCLD by 08/27/2024 : • Copy of updated Administrator Certificate • Copy of facility's liability insurance • LIC400 Affidavit Regarding Client/Resident Cash Resources • LIC610E Emergency Disaster Plan • LIC500 Staff Schedule • Copy of control of property or copy of lease No citations issued. Report is reviewed with Joan and a copy is provided on this day.

On 6/24/24, San Bruno Regional Office conducted a non-compliance conference meeting with Executive Director, Joan Newman, Attorney Joel Goldman, Regional VPO Mark Maclaine, Director of Compliance Holly McMurry. Present in the meeting was Regional Manager, Vivien Helbling, Licensing Program Manager, April Cowan, and Licensing Program Analyst, Grace Donato. During non-compliance meeting, the following violations were discussed, 87468.1(a)(2) Personal Rights of Residents in All Facilities, 87470(b)(2) - Infection Control Requirements, 87211(a)(2) - Reporting Requirements, 87466 - Observation of Resident, 87464 - Basic Services, 87468.2(a)(4) - Additional Personal Rights of Residents in Privately Operated Facilities, 87463(a)(4) - Reappraisals. During this meeting, it was discussed, Licensee will receive more frequent monitoring inspection visits to ensure compliance with this compliance plan and Title 22 Regulations for 2 years. Licensee was provided the link below for resources and guidance to improve facility operations: https://www.cdss.ca.gov/inforesources/community-care/resource-guide-for-providers

LPA Jeung met with executive director in response to facility's organizational changes. RCFE Disclosure Worksheet (LIC606)--including organization chart--was submitted to CCLD, which identifies Cogir Management USA Inc. as licensee/co-licensee. According to Administrative Organization (LIC309), 9388-0045 Quebec Inc. owns 100% interest, and is the parent company of Cogir Management USA Inc. Cadence Senior Living, LLC no longer holds ownership interest in this facility, as it was acquired by Cogir, as per information on Cogir website dated November 2022. RCFE license was issued to licensee 1201 Operator-LLC/Cadence SL Millbrae LLC,, with Cadence as the management company. Since Cadence was acquired by Cogir, and is now managing the facility, the entity that is now operating the facility is required to apply for RCFE licensure. Deficiency of the California Code of Regulations, Title 22, is cited on a following page.

LPA Jeung met with business office manager and executive director to discuss 8 recent move-ins from Belmont RCFE. LPA observed 2 apartments occupied by new residents and met one resident. Other than numerous boxes that needed to be unpacked, no health or safety issues are observed. Administrator is reminded to ensure that required admission documents are completed--admission agreement, physicians' report, appraisals, emergency information, etc. LPA spoke with vice-president of operations and reminded her to submit documentation to designate Mr. Sharkey as administrator, including board resolution. Also discussed was the corporate organization, which added Cogir Corp. in December 2022. No deficiencies are observed today.

LPA Jeung met with business office manager to follow up on Suspected Abuse Report submitted to CCLD on 9/12/22. No additional information was provided about this suspected financial abuse of client #1 b ecause the incident was handled by executive director who is no longer employed. LPA obtained details of the incident, including law enforcement case number, name and contact number of sheriff. No deficiency cited today.

LPA Jeung met with business office manager to obtain additional information about Suspected Abuse Report submitted to CCLD. Because investigation is still pending and was handled by executive director who is no longer employed, additional information is not available. LPA to be updated regarding this incident by regional vice president. Updated Personnel Report (LIC500) to be submitted to CCLD BY 9/29/22.

LPA Jeung observed memory care client who resides in room 2103A, and observed location of the room on the 2nd floor--identified as the 1st floor. As per Incident Report submitted to CCLD, client left building unattended on 3/13/22, and was found an hour later, at his residence, less than a mile away. Given that he resides on the 2nd floor--and the elevator can only be accessed by entering a code and there is a 30-second delayed egress on the ground floor--staff are unable to determine how resident was able to get to the ground floor and exit the building. Physician's Report and updated Service Plans were submitted to LPA upon request and reviewed. In addition, documentation of staff participation in an Elopement Drill was submitted. No deficiency cited.

In response to capacity change application for 165 elderly residents--105 non-ambulatory and 60 ambulatory--LPA Jeung toured new memory care unit, consisting of 6 shared rooms on ground floor and 6 shared rooms on 1st floor (2nd level). Each unit has a shared bathroom with shower stall; grab bars are installed in shower stalls and by toilets. There are Arial call alerts installed in each unit, and in each of the bathrooms, but Mr. Stromgren stated that these will not be used by the residents in this unit due to cognitive limitations. All units have either a sliding glass door that accesses a metal railing or sliding windows; all are secured and only open 4 inches. There is a dining room with warming pads on both floors; LPA observed dining chairs for 12 in each dining room. Fire clearance has been approved, including two 30-second delayed egresses on both floors of memory care unit. An enclosed courtyard on the ground floor is secured by a gate that is accessed by a keypad, leading to the parking lot. Stairwells are also accessed by a keypad. LPA also toured existing memory care unit on 1st floor (2nd level), where 14 residents reside. Paper towels are not available in bathrooms, nor were liquid pump hand soap and handwashing reminder signs. The following observations are made and discussed with Mr. Stromgren: 1. There is no COVID signage in the memory care unit, including handwashing, mask wearing and social distancing reminder signs. 2. Liquid soap and paper towels are not present in bathrooms. 3. Vestibule on ground floor accesses memory care unit and parking lot. The vestibule can be accessed from the memory care unit by a 30-second delayed egress. This room designation is currently unknown. During the pandemic, LPA advises that the vestibule not be used as an egress. Memory care unit is not yet ready to accommodate residents. LPA to be notified when the above items have been addressed.

LPA Audrey Jeung toured facility and grounds, consisting of 158 studio and 1-bedroom units on 5 floors. Eighteen rooms comprise the memory care unit on the first--not ground level--floor, where there are 2 exits equipped with a 30 second delayed egress: one is tested and opened immediately with an alarm. This unit has a small dining room. The rest of the building accommodates independent and assisted living residents, including non-ambulatory, bedridden and hospice residents. Rooms are equipped with emergency call systems, which can be activated from bathrooms and bedrooms. There is a large dining room for independent and assisted living residents on the 1st--not ground level--floor, with an adjacent enclosed outdoor courtyard. Near the main dining room is the activity room and piano lounge. No accessible bodies of water or fire safety hazards observed. Facility is currently undergoing some construction and renovation: Ground floor and 1st floor rooms in building 2 are being renovated to accommodate a new memory care unit; beauty salon on ground floor is being converted to resident room and staff office; new beauty salon is located on ground level behind reception desk; med room on 1st floor is being enlarged; two additional resident rooms are being added; upon completion of new memory care unit, current memory care unit will be renovated and upgraded to accommodate assisted living or independent residents. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is adequate. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Liquid soap is available in common bathrooms and private bathrooms of independent and assisted living bathrooms, but not in memory care bathrooms, for the safety of memory care residents. First-aid kit is inspected and complete. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Kiel Stromgren is a certified RCFE administrator (x 5/22) that oversees facility operations. 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 The following updated forms/information are requested to be submitted to CCLD BY 8/2/21: • LIC 500 Personnel Report • Proof of current Liability Insurance • LIC 808 COVID Mitigation Plan Emergency Disaster Plan (LIC 610E revised) is given to LPA today. No deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are cited. See Technical Violations and Advisories issued.

Licensing Program Analyst (LPA) Jeung met with Administrator, Kiel Stromgren, to follow up on Death Report submitted to CCL Office on 2/24/21. The Dept. has investigated the circumstances of the death of client on 2/23/21 and determined that his death was not questionable, but natural. Client was found in his room unresponsive and 9-1-1 was called. Facility records document that client was independent and did not require--nor did he receive--any care or supervision, including medication management. Based on Death Certificate, cause of death was determined to be related to heart failure. No deficiencies are cited based on this incident.