Aegis Assisted Living of Moraga

On 01/21/2026 at 12:30 PM, Licensing Program Analysts (LPA) David Doidge arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with General Manager Tianna Henderson and explained the purpose of the visit. LPA toured the facility including but not limited to, bedrooms, bathrooms, multiple activity rooms, kitchen, and common area. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 72 degrees Fahrenheit. The hot water temperature in a common bathroom was measured at 113 degrees Fahrenheit. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps are locked and inaccessible to residents in care. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 12/30/2025. Emergency disaster drills are conducted monthly, with the last one conducted on XXX. First aid kit was observed to be complete. LPA reviewed five (5) resident records and five (5) staff records, all were complete. No deficiencies observed or cited during this visit. Exit interview conducted and a copy of this report provided

LIC9099-C (Page 2) Allegation: Staff billed resident for services not being rendered by staff. Finding: Unsubstantiated On 10/30/2024, LPA L. Alexander interviewed Witness (W1). W1 stated that R1’s care plan increased from $15,000.00 to $20,000.00. W1 reported that they were billed for 30 days but only paid for 5 days, at approximately $6,000.00. W1 stated that facility only discussed points but never discussed the money. On 10/31/2024, LPAs Alexander and Doidge interviewed Staff (S1, S2 and S3). S2 stated that R1’s Individualized Service Assessment dated 03/18/2024 totaled 324 points. S2 reported completing a reassessment on 08/06/2024, which resulted in 447 points. S2 explained that once the assessment is completed, the billing department calculates the rate. S2 stated they contacted W1 via email to discuss the new assessment and requested a care conference, but W1 did not respond. S3 reported that they complete resident billing each month. S3 explained that when a new assessment is completed, they enter the total points into the billing system, which calculates the updated rate. S3 stated that they attempted to explain the charges to W1 by phone, but W1 became upset and disconnected the call. S3 further reported that the Responsible Party (RP) removed R1 from the facility on 08/26/2024. S3 also stated: The August billing statement dated 07/18/2024 totaled $15,498.76. A new assessment completed on 08/22/2024 changed the rate to $353.13 per day. This rate applied to the period 08/22/2024 through 09/30/2024 (40 days). Adjustments were made to the account, resulting in a credit of ($6,654.96). Based on interviews and records reviewed, the allegation that staff billed the resident for services not being rendered is unsubstantiated . LIC9099-C Continued... 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 LIC9099-C (Page 3) Allegation: Staff did not follow resident's care plan (DNR). Finding: Unsubstantiated On 10/30/2024, LPA Alexander interviewed Witness (W1), who stated that on July 3, 2023, R1 was under hospice care with Suncrest Hospice and had a “Do Not Resuscitate” (DNR) order in effect. W1 stated that an Aegis Moraga night care staff member summoned paramedics rather than contacting the hospice team. W1 reported being contacted by paramedics who stated that R1 had been resuscitated. W1 further stated that a hospice representative also contacted them immediately and expressed concern regarding a breach of protocol by facility staff. On 10/31/2024, LPAs Alexander and Doidge interviewed Staff (S1, S2 and S4) regarding allegations that CPR (Cardiopulmonary Resuscitation) was rendered to R1, who had a DNR on file, around 07/03/2023. S1 stated they were not aware of this incident and reviewed facility records for any corresponding incident report. S1 stated that no LIC624 (Unusual Incident Report) was found in R1’s file. S2 stated that they were not working at the facility during that time period. S4 was interviewed by phone and stated that if any such incident had occurred, it would have been documented in facility records. S4 stated they do not recall any incident involving R1 that required 911 response or CPR being rendered. On 11/04/2024, LPA Alexander contacted Suncrest Hospice and spoke with W2. W2 confirmed that R1 was discharged from hospice services on 03/14/2023 and re-admitted on 05/26/2023. W2 stated there were hospice notes dated 07/03/2023 for an assessment but nothing in their records indicating a 911 call or CPR performed by emergency personnel. LIC9099-C Continued... 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 LIC9099-C (Page 4) LPA reviewed the Moraga-Orinda Fire District “Patient Care Report” dated 07/03/2023, which documented an EMT response to the facility at approximately 2135 hours. The report indicated that R1 experienced a syncope episode, was conscious, awake, and alert upon EMT arrival, and had no medical complaints. The report revealed that R1 declined transport to the hospital, and the EMT contacted R1’s Power of Attorney, who also declined transport. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that staff failed to follow R1’s care plan or disregarded a DNR order. Records reviewed indicate that while emergency medical services were contacted, no resuscitation efforts were performed, and R1 remained stable at the scene. 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. A copy of this report were provided to General Manager, Tianna Henderson.

On 05/09/2025 at approximately 1:30 PM License Program Analyst (LPA) David Doidge arrived unannounced to conduct a case management visit regarding an Unusual incident report (UIR) that was reported to CCLD on 04/25/2025. LPA met with Tianna Henderson General Manager (GM) and explained the purpose of the visit. LPA Spoke with General Manager and the Medication Care Manager (S1). The UIR stated that the resident was given two (2) tabs instead of one tab as directed on the bubble pack. The incorrect dosage given was caused by an error from the pharmacy. The Pharmacy entered two (2) tabs as the dosage in the Electronic Medication Administrator Record (EMAR) and the bubble pack showed one (1). The Medication Care Manager (S1) caught the error when administering the dose and informed the pharmacy to have EMAR updated. Correct dosage has since been administered. Per GM retraining on medication was also performed. Resident’s spouse and PCP were updated. Resident was monitored with no negative side effects. No deficiencies observed or cited during this visit. . Exit interview conducted and a copy of this report provided

On 01/14/2025 at 08:15 AM, Licensing Program Analysst (LPAs) David Doidge and James Sampair arrived unannounced to conduct an annual required inspection. LPAs met with General Manager Angeles Sticka and explained the purpose of the visit. LPA toured the facility including but not limit to, bedrooms, bathrooms, multiple activity rooms, kitchen, and common area. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 72 degrees Fahrenheit. The hot water temperature in a common bathroom was measured at 120 degrees Fahrenheit. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps are locked and inaccessible to residents in care. Fire extinguisher was last serviced on 12/18/2024. Emergency disaster drill are conducted monthly, last conducted on 12/20/2024. LPA reviewed five (5) resident records and five (5) staff records, all were complete. No deficiencies observed or cited during this visit. . Exit interview conducted and a copy of this report provided

On 01/26/24 at 12PM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct an annual required inspection. LPA met with co-administrator (Co-ADM) and explained the purpose of the visit. Co-ADM has a current administrator certificate # 6041047740 which expires 06/15/2024. At 1:30PM, LPA toured the facility with Co-ADM including but not limited to the front entrance, screening station, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, residents and visitors. An electronic sign-in policy, digital scanner temperature device, additional face masks and hand sanitizers were observed at the front desk screening station. LPA observed 2 memory care units located on the first floor with 24 memory care residents. LPA also observed 40 assisted living residents located on the second floor. Emergency Disaster Plan, Complaint poster, Personal rights, Cough/sneeze etiquette, proper hand-washing signs were observed posted in common areas. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs, paper, medications locked in cabinets. Comfortable temperature is maintained at 72 deg F. Hot water temperature was measured at 118 deg F. Facility has a mitigation plan in place and the infection control leader is the administrator. Inside and outside pathways were free of obstruction and fire hazards. Smoke and Carbon monoxide detectors were operational. LPA reviewed 5 staff and 5 resident files. LPA also conducted 5 staff and 5 resident interviews during visit. Continue on next page, 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 At 3:45PM, LPA obtained updated copies of the following documents for facility file:  LIC500- Personnel Report  Residents Roster  LIC308- Designation of Facility Responsibility  LIC610E- Emergency/Disaster Plan including infection control plans  Evidence of Liability Insurance No deficiencies observed during visit. Exit interview conducted and a copy of the report provided.

On 12/14/2023 Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced case management visit regarding a SOC 341 self-reported incident that occurred on 12/7/23. LPA spoke with Amria Angeles Sticka, Executive Director and explained the purpose of the visit. LPA received an SOC 341 self-reported regrading a resident hitting another resident well in the community. LPA interviewed S1 regrading the incident. S1 stated that the situation has been resolved. S1 spoke with the victim family members and explained the situation. R1 was being treated for UTI and now is calmed. S1 had the following plan implement. - R1 was being evaluated by the physician. - Internal investigation of the caused of R1 irritation. - R1 was assigned a one on one after that incident. - LVN did an assessment on R2 for any injury (found no injury) LPA reviewed: - Physician Notification - PCP notification of R1 behavior - Change in medication. - S1 Communication between R1 family member regrading R1 change in behavior. - S1 Communication with R2 family member No deficiencies cited. Exit Interview conducted and a copy of this report provided via email.

It was alleged that Staff do not provide proper incontinence care to residents in care Based on observations, LPA observed incontinence supplies in the memory care wings, LPA observed a sufficient amount of diapers, wipes and gloves. Based on interviews with staff (S1, S4 and S5), incontinence residents are checked on and changed every 2 hours. When asked about incontinence supplies, S4 and S5 stated that supplies can be low with Hospice residents due to limited supplies and wrong sizes. Based on interview with Care Director (CD), Hospice agencies send incontinence supplies weekly without CD needing to request. Other incontinence supplies are restocked by CD and placed in four different locations (in an unlocked cabinet in the Wellness Center, in a locked area/closet in each memory care wing and in an overstock closet that CD has access to). It was alleged that Staff do not provide proper medication assistance to residents in care Based on interview with CD, med techs (Medication Care Manager), the Associate Care Director, the Wellness Nurse and CD themselves dispense medication. There are seven med techs on staff, and five work during the day (two during AM shifts, two during PM shifts and one during NOC shifts). Based on interview with resident (R1), R1 has not experienced any issues with their medications. R1 stated that staff knocks on their door and dispenses their medications without issues. It was alleged that Facility is not kept clean Based on observations, LPA observed the facility to be clean and without odor. Housekeeping staff were observed cleaning the facility during the initial visit. Based on interviews with staff (S3, S4 and S5), the facility is kept clean. S4 stated that on average they observe housekeeping sanitation three times per their shift. Based on interview with Executive Director (ED), resident apartments are cleaned once a week, unless they have an accident and/or need it to be cleaned more frequently. The whole facility is cleaned every day by housekeeping. Report continues on 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 It was alleged that Facility is not kept free of pests Based on observations, LPA did not observe any pests during the initial visit. Based on interviews with staff (S1 and S4), spiders are common in the memory care unit. S4 stated that they have observed spiders, roaches and stated that for some time there was a cricket in one of the hallways in the memory care wing. Based on interviews with Executive Director (ED) and Maintenance Manager (MM), the facility has a contract with Western Exterminator Company, the facility is inspected every month and treated as needed. Staff can report to MM when they observe pest, MM contacts the exterminator and the facility gets treated with the best mode to eliminate pest (such as traps and sprays). Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED . Exit interview conducted and a copy of this report provided.

On 1/17/2023 starting at 11:50 a.m., Licensing Program Analyst (LPA) Catherine Lin arrived unannounced to conduct Infection Control Inspection. LPA met with the Administrator and disclosed the purpose of the visit. Upon entry, LPA observed Accushield machine was in place for check-in. LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, bathrooms, kitchen, common areas, and outdoor areas. There is one central entry point for universal screening for staff, residents, and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a sufficient 2-day perishable and one-week non-perishable food supply. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has Infection Control Plan, Emergency Disaster Plan, and maintains record of routine screening for residents, staff, and visitors. No deficiency cited during visit. Exit interview conducted with Director of Resident Services, and a copy of this report provided.

Allegation: Residents are being left in soiled diapers – Unsubstantiated. The Department has investigated this allegation and per records review and interviews and found that no resident was identified being left in soiled diapers. 6 residents (R3, R5, R6, R7, R9, and R10) and 2 witnesses (W1 and W4) stated that residents were assisted with changing diapers as needed. Allegation: Residents are not being showered timely – Unsubstantiated. The Department has investigated this allegation and per records review and interviews and found that residents on shower schedules were assisted with showering on time. 5 residents (R3, R5, R6, R7 and R10) and 1 witness (W4) stated that residents got showers 2-3 times per week. Allegation: Residents are falling due to insufficient staffing – Unsubstantiated. The Department has investigated this allegation and per records review and interviews and found that 2 residents (R1 and R2) were reported unwitnessed fall in subject time period, R1 didn’t remember fall had happened. R2 was not alert, R2’s family member W2 stated that R2 has been cared well by staff and has not observed staffing shortage issue. No additional information is obtained to allege falling due to insufficient staffing. 5 residents (R5, R6, R7 R9 and R10) and 1 witnessed (W1) stated that staff showed up as quickly as within 5-10 minutes when residents pressed their call button. Based on observation, records reviewed, and interview conducted, the above allegations are 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, therefore the allegations are unsubstantiated. No deficiency cited, exit interview conducted with GM, and a copy of this report provided.

Allegation: Staff are not providing adequate food service for resident's– Unsubstantiated The Department has investigated this allegation and per interviews, records review, and observations, 2 residents stated that food was served in nice and warm, 6 out of 7 caregivers stated that food was served in warm. 2 caregivers stated that food could become cold if residents couldn’t finish it in short period of time, caregivers microwaved it sometimes. 6 out of 7 caregivers stated that forcing residents to eat was not observed or witnessed. Sufficient food was observed in the kitchen durin g visit. Allegation: Facility is not clean– Unsubstantiated The Department has investigated this allegation and per interviews, records review and observations, facility was observed clean and has no smell during visit. 6 out of 7 caregivers stated that they have been instructed and trained to maintain facility clean, they cleaned up residents’ mess as needed when housekeeper was not scheduled. Although the allegations may have happened or is valid, there is not a preponderance of evidence to provide the alleged violation did occur, therefore the allegations are UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted with Business Office Manager, and a copy of this report provided.

On 2/18/2022 starting at 11:00 a.m., Licensing Program Analyst (LPA) Catherine Lin arrived unannounced to conduct Infection Control Inspection. LPA met with staff Felicided Ybona and disclosed the purpose of the visit. (Administrator, Richard Pielstick later arrived approximately 12:00pm.) Upon entry, LPA’s temperature was checked by the staff and asked to fill out Covid-19 questionnaire in the Accushield. LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, bathrooms, kitchen and common areas. There is one central entry point for universal screening for staff, residents, and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a sufficient 2-day perishable and one-week non-perishable food supply. Facility has a 30-day supply of PPEs that were accessible for staff. Facility has Mitigation Plan, Emergency Disaster Plan, and maintains record of routine screening for residents, staff, and visitors. No deficiency cited during visit. Exit interview conducted with Administrator, and a copy of this report provided.