Loma Clara Senior Living

On 11/20/2025, LPA interviewed Executive Director (ED), ED stated resident R1 lives in the assisted living unit. ED stated R1 had doctor prescription medication 25 mg M1 to take one pill as needed at bedtime to help for sleeping. ED stated the facility did not know that R1 ordered the medication M1 by himself/herself and hid in his/her room. ED stated on 11/13/2025, R1's family member (FM) visited R1 and found R1 had symptoms of stroke and called 911. R1 was sent to hospital. ED stated on 11/14/2025, R1 told hospital nurse that he/she had trouble of sleeping and took several pills of medication M1 per day. ED stated R1 ordered M1 online and the package of M1 was delivered to the facility. ED stated the facility did not open R1's package because of the right of privacy. ED stated R1 did not tell any facility staff that he/she ordered medication M1 online. ED stated the facility staff did not see medication M1 in R1's room because R1 hid it. ED stated R1 had packages from Amazon delivered to the facility on 09/30/2025, 10/102025, 10/142025, 10/15/2025, and 11/10/2025 but were unable to know which packages had medication M1. ED stated on 11/17/2025, FM came to R1's room to search R1's room and took all medication M1 from R1's room and R1's Amazon account was closed by FM. ED sated on 11/17/2025, R1's doctor stopped the prescription of medication M1. On the same day, LPA interviewed R1 in R1's room. R1 stated he/she had medication M1 several pills per day before but not recently. R1 stated he/she does not remember the exact date that he/she stared to take M1. R1 stated the reason that he/she takes M1 is because he/she wants to have good sleep. R1 stated there is no more M1 in the room because FM removed all M1 from the room. R1 stated he/she ordered M1 from store and hid in the room but did not tell any staff. R1 did not want to reveal where he/she hid M1. LPA interviewed Director of Assisted Living (S1). S1 stated he/she received a phone call from the hospital nurse on 11/14/2025 that R1 had several sleeping medication M1 pills per day for several days. S1 stated R1 had doctor prescription medication M1 one pill per day as needed at bedtime. S1 stated the facility did not know R1 ordered M1 online. S1 stated the facility does not open resident's package without resident's permission because of privacy rights. S1 stated on 11/17/20205 FM came to R1's room and removed medication M1 from the room and closed R1's Amazon account. LPA interviewed staff S2. S2 stated R1 had p rescription PRN medication M1 one pill per day at night. S2 stated the facility only gave M1 one pill at night per day when R1 requested. Continue on LIC9099-C. Page 2 of 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 S2 stated he/she never saw R1 had his/her own medication M1. S2 stated he/she never saw M1 left in R1's room. LPA interviewed 2 caregivers. Both stated they did not administer medication to R1 and did not see any medication M1 in R1's room. Based on the review of R1's doctor order, R1's had prescription medication M1 one pill per day as needed at bedtime, and was stopped on 11/17/2025. Based on the review of R1's Medication Administration Records, a 25 mg M1 pill was administered to R1 on 11/01/2025 to 11/06/2025, and 11/08/2025 to 11/12/2025. Based on the review of the incident report, on 11/21/2025, the facility conducted a room search for R1's room by Director of Assisted Living and Med Tech, a bottle of medication M1 was found under the mattress. The bottle of M1 was removed from the room. R1 was sent to hospital for evaluation. R1 was sent to skilled nursing Rehabilitation facility . The department has investigated the above allegation. Based on the observations, records reviewed, and interviews conducted, the Department found that the above allegation is UNSUBSTANTIATED . An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. No deficiencies or citations noted at today’s compliant investigation visit. Exit interview conducted with BD. A copy of this report was provided to BD. Page 3 of 3.

On November 13, 2025, Licensing Program Analyst Manuel Monter arrived at the facility unannounced to conduct a case management – other visit. LPA met with Kayree Shreeve Resident Care Director (RCD) The purpose of the visit is to hand deliver an immediate exclusion letter for an individual (S1) who the Department determined engaged in conduct inimical. RCD stated S1 was not currently working in the facility and his/her last day September 30, 2025. The immediate exclusion letter was handed to the RCD. The RCD was informed to remove S1 from any contact with clients and not allow S1 to be physically present in the facility. The RCD was advised to separate S1 from the facility roster. LPAs requested a copy of the updated LIC 500. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Kayree Shreeve Resident Care Director and a copy of the report was provided.

They couldn’t prove it. There wasn’t any action plan the facility covered with RP. They said they didn’t really think it happened and supposedly they were keeping eye on them, don’t know if R1 was following R2 around. After the incident on 08/09, they met with them that Saturday morning and Maria (former memory care director) said it was really odd that it happened. LPA Kabariti (Christine Dolores) interviewed staff members. According to ED, there was an incident that occurred between R1 and R2. Both residents are in memory care. There was a caregiver (S3), who saw them walking in the memory care's courtyard. There are windows to the courtyard and the caregiver clearly saw both residents. Both residents are ambulatory and independent. When R1 and R2 met at a crossing path, they don't know exactly what happened between them and what was said, but according to S3, R1 pushed R2 and R2 fell into the bush and ended up sideways from the walking path. LPA Donato was able to interview S3. S3 shared that he/she saw R1 push R2 so he/she ran to keep them away from each other. Based on records review, in one of the entries in the progress notes, the former memory care director had a meeting with family members on 8/10/2024 to go over the service plan regarding the incident that happened. Regarding the allegation of Staff did not ensure resident was adequately fed resulting in weight loss, RP stated that in the process of moving R1, RP learned he's lost 8 lbs. The reason R1 is in the facility is because R1 wasn't eating well at home and was only drinking calories so if anything, R1 should have gained weight with regular meals. According to interviews, ED said that there were no concerns regarding R1s weight. R1 did a lot of walking and had a personal trainer that come here every week. Personal trainer was to keep him active. R1 was able to articulate and verbalize what he/she wanted. ED didn't notice he was losing weight. ED added that R1 verbalizes what he/she wants. If R1 needs more food, he/she asks for it. page 2 of 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 Based on records review, R1 had a logged weight record done by the facility every month. The records show that while the weight of the resident differs every month it is between 2.8lbs-6lbs. For July 1, 2024, the weight on record is 177.6 and when R1 got weighed again on August, 12, 2024, the records show 182lbs. For the allegation that Staff did not inform resident's responsible party about resident's change of condition, RP shared that they have learned that R1 has a horrible nail fungus on the toes. Facility should have helped R1 shower so someone should have alerted us (RP) to the toe fungus problem. During the interview, ED shared that they were not aware of any infections, fungus on R1s body and toe fungus. Don't remember anything of that effect. ED was not aware of any change of condition. If there was any change of condition it should be in the progress notes. ED also shared that R1 always has socks on. S2 mentioned that R1 was independent and performed his/her own Activities of Daily Living (ADL). S4 shared that he/she only observed R1s toenails to be long. If the fungus is under, then they won’t be able to see it. There is a podiatrist that comes in the facility to cut the residents nails. S4 also shared that R1 is good at dressing himself/herself. According to the records reviewed, R1 is an ambulatory resident who can do his/her own bathing, dressing feeding and toileting needs. R1 is also capable of communicating his/her needs and can follow instructions. In R1s care plan, R1 needs verbal cue or reminders to shower, dress and groom. Care staff is to assist with setting out clean clothes and redirect verbally if needs change in clothing and show if needed. There is also verbal cueing to assist what comes next in grooming. Based on interviews and records review, the department has determined that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Report is reviewed and copy is provided. page 3 of 3

Based on staff interview, it was stated that it was staff’s responsibility to keep an eye on R1’s oxygen concentrator to make sure it is working properly. Staff stated that R1’s family has complained that the light of the oxygen concentrator was turning yellow and now the staff are trained to contact the hospice agency if the oxygen concentrator light turns yellow. Staff denied the observation of the oxygen concentrator not working properly. On 12/1/2022, LPA observed the light on R1’s oxygen concentrator was green. Based on record review, the facility was monitoring R1’s oxygen concentrator, however, there were no notes on 10/25/2022 regarding R1’s oxygen concentrator not working properly. It was alleged that facility staff did not ensure that resident’s room is free of odors as R1’s room smells like urine usually around 10:00am – 11:00am. It was stated that staff are masking the smell with Febreeze and since 11/24/2022, it hasn’t happened again for the past 3 weeks. Based on staff interview, it was stated that staff try their best to air the resident’s room out if a resident soils their diapers, clothing and/or linens. Another staff stated that when a resident for example has a BM, they leave the smell because they are not allowed to have sprays. It was stated that if the resident is not in the room, they can open the window to air out, however, if the resident is in the room they don’t open the window because it can be too cold. On 12/1/2022 around 10:45AM, LPA entered into 10 random apartments in memory care. LPA observed 1 out of 10 apartments had an odor of urine. Based on staff interview, staff was still working on getting the resident’s soiled laundry that was placed inside the resident’s hamper. LPA observed 9 out of 10 apartments did not have an odor of urine in the room. Page 2 of 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 It was alleged that staff did not properly dispose of resident’s soiled diapers. Based on photographs obtained from the reporting party, it shows 2 pictures of black garbage bags that is tied and placed on the floor next to the resident’s hamper and placed on top of the resident’s bed. Based on the reporting party, the black garbage bag contained soiled clothing items. Another picture shows a diaper that was placed on top of a table in which the reporting party stated was soiled. Based on observation of the picture, it is unclear whether the diaper was soiled as it only shows the outer part of the diaper. On 12/1/2022, LPA entered into 10 random apartments in memory care. LPA observed 1 out of 10 apartments had soiled clothing inside of the resident’s hamper. Based on staff interview, staff was still working on getting the resident’s soiled laundry that was placed inside the resident’s hamper. LPA observed 1 out of 10 apartments did not have bed sheets. Based on staff interview, it was stated that the resident’s sheets were being washed because the bedding was soiled. LPA observed the remainder of the apartments did not contain any soiled items that were not disposed of properly to include diapers, linens, and clothing. Based on staff interview, soiled diapers should be stored in a plastic bag and thrown out right away in the trash bins. It was alleged that the facility staff does not change the resident out of their night clothes, as it was observed that R1 was sitting in the lobby in his/her nightgown before noon time. Based on staff interview, it was stated that the residents clothes are changed when they help get them up in the morning before breakfast. It was stated when the PM shift starts (around 2:00pm), R1 was always observed in his/her day clothes. Staff denied observing R1 in his/her nightgown as R1’s family was so strict about ensuring R1 was changed out of his/her pajamas. Page 3 of 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 On 12/1/2022 around 11:00am, all residents seated in activity room was observed dressed in day wear and not observed in pajamas and/or night gowns. It was alleged that the facility did not take measures to ensure R1’s mattress pad did not go missing. It was stated that R1 and R1’s responsible party did not safeguard the items that went missing. It was stated that R1’s responsible party was reimbursed by the facility for the mattress bad. Based on record review of R1’s safeguard of personal properties and valuables form, a “queen bed” was listed, however, it was unclear of what items of the queen bed was entrusted to the facility. It was alleged that facility staff do not wash the resident’s hands after meals. The reporting party stated the observation of one incident where a staff member was getting towels and a washcloth stating it was to wash the resident’s hands, but the reporting party was unsure whether staff wash the resident’s hands every day. Based on staff interview, it was stated that the staff are supposed to assist residents with hand washing before and after meals. Staff stated that hand washing also occurs after the resident uses the bathroom. Based on record review, on 12/2/2022, the facility provided an in-service training with the staff regarding hand washing. The Department has investigated the above allegations. Based on interview, record review and observation the above allegations are unsubstantiated. An unsubstantiated finding indicates that although the allegations may have happened and/or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Executive Director, Eugenia Smith and Generations Program Director Erin Wiley and a copy of the report was provided. Page 4 of 4.

Based on interview with staff (S1), it was stated that during R1's medical appointment, R1 informed his/her doctor of an incident that occurred with R1 and a former resident back in August 2024 wherein a male resident had pushed R1 in the courtyard. Since then, R1 had complained of leg pain. S1 denied any incidents of a staff member physically abusing R1. It was stated that R1 is fully ambulatory and is able to provide his/her ADL (activities of daily living) care to include getting in and out of bed. It was stated that R1 only needs assistance with medication and stand-by showers provided by female caregivers. S1 stated that they have 2 male caregivers in Generation who do not provide any care to R1, due to R1's preference. On 03/12/2025, a witness was interviewed. Based on interview, it was stated that the incident did not occur with a staff but rather with a former resident. The witness did not have any complaints or concerns regarding staff treatment towards R1. On 03/12/2025, resident (R1) was interviewed. Based on interview, R1 denied any staff members hurting him/her. R1 states that he/she does most ADL care by him/herself and only needs stand-by assistance during showers and assistance with medication. R1 denied any male caregivers providing any care to R1 and states only female caregivers provides care to R1. On 03/12/2025, a staff member was interviewed. Based on interview, the male caregivers do not provide any physical care to R1. Based on record review, R1 is diagnosed with vascular cognitive impairment. The Department has investigated the above allegation. Based on interview, record review and observation the above allegation is unfounded, meaning, the allegation is false, could not have happened and/or is without a reasonable basis. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Business Office Director, Cassandra Pace and Generations Program Director Erin Wiley and a copy of the report was provided.

It was alleged that the facility staff did not allow resident (R1) to have phone calls and visitors. On 02/10/2022, LPA Donovan interviewed 3 staff members. Based on staff interview, R1 has a cell phone and the facility has a land line/ house phone that receives incoming calls as well. Staff denied programming R1’s phone to block calls. It was stated that visits are based on the resident’s choice and are allowed as long as they meet the screening process. 3 out of 3 staff denied denying visitations and denied preventing R1 from receiving phone calls. It was stated that R1 preferred not to be alone with a certain visitor. It was stated that when this specific visitor visits R1, a staff member will be present with the consent of R1. On 02/10/2022, LPA Donovan interviewed R1. Based on resident interview, R1 does not want to see a particular visitor. R1 states he/she has a cell phone. The review of records shows that R1 did not want to see a particular visitor and wished for the facility staff to intervene if this visitor attempts to take R1 out of the community. The Department has investigated the above allegations. Based on interview and record review the above allegations are unfounded, meaning the allegations are false, could not have happened, and/or is without a reasonable basis. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Executive Director, Eugenia Smith and a copy of the report was provided. PAGE 2 OF 2.

On 09/05/2024, 2 staff members were interviewed. Based on staff interviews, it was stated that on 08/25/2024 an incident happened between resident (R1) and R1's family members. The front desk staff observed R1 and R1's family member having an argument in the facility's parking lot. The front desk staff called the memory care director for assistance, and by the time the memory care director arrived the resident was already inside the facility. Based on interview and record review, the facility's staff were not in the parking lot and involved in the argument between R1 and R1's family members. Intervention with staff happened when R1 was already in the community. The Department has investigated the above allegations. Based on interview, record review and observation the above allegations are unfounded meaning the allegations are false, could not have happened and/or is without a reasonable basis. No deficiencies were cited per California Code of Regulations, Tile 22. This report was reviewed with Executive Director, Eugenia Smith and a copy of the report was provided. PAGE 2 OF 2.

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management - other visit. LPA met with Senior Resident Care Director (SRCD), Julie Mayder. The purpose of the visit was to advise the facility of Title 22 regulations regarding Restricted Health Condition for Indwelling Urinary Catheters. During visit, LPA advised SRCD on the Title 22 regulations for Indwelling Urinary Catheters and the exception request process. LPA advised that the facility may retain residents with a restricted health condition as long as the resident meets the circumstances in the Title 22 regulations section 87623. Based on interview, the facility currently has 1 resident (R1) who has an indwelling urinary catheter in Generations, also known as Memory Care. The resident had an exception request that has been approved by the Department in July 2023. The facility had another resident (R2) in Generations who had a temporary urinary catheter from 11/16/23 - 12/07/23. The Department did not receive an exception request for R2. LPA advised SRCD on going forward regarding the exception request process for restricted health conditions - indwelling urinary catheters. LPA advised the facility to reach out to the Department for any questions or concerns. LPA advised to review Title 22 Regulation Section s 87616 - Exceptions for Health Conditions, 87612 - Restricted Health Conditions, and 87623 - Indwelling Urinary Catheter. No deficiencies were cited per California Code of Regulations, Title 22. Advisory note provided. This report was reviewed with Senior Resident Care Director (SRCD), Julie Mayder and a copy of the report was provided.

The review of records shows on 01/18/2023, R1 sustained an unwitnessed fall and minor injury to the head. 911 was called but family refused to send R1 to the hospital as they felt it was not necessary. On 01/19/2023, a Nurse Practitioner evaluated R1 and encouraged R1 to be sent to the hospital for evaluation, however, R1’s family refused as they did not think it was necessary. Facility staff continued to monitor the resident. On 01/20/2023, it was noted that the Executive Director (ED) informed R1’s representatives of the facility’s responsibility to ensure R1’s safety after the fall by requiring a one-to-one companion during the night. The night of 01/20/2023, one-to-one companion was endorsed. The review of R1’s January 2023 invoice did not indicate a service for a one-to-one companion was charged. Based on interview on 02/01/2023, the ED stated R1 was not billed for the one-to-one companion due to R1’s departure from the facility on 01/28/2023. The Department has investigated the above allegation. Based on interview, record review and observation the Department has determined that the above allegation is UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Interim Executive Director, Becca Black and a copy of the report was provided.

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management – incident visit based on an incident report and death report received for resident (R1). LPA met with Executive Director (ED), Jett Cabuena. On 04/05/2023, the Department received an incident report and death report for resident (R1). On 03/29/2023, R1 was eating breakfast in the dining room when it was observed R1 was choking on food. Staff immediately administered the Heimlich Maneuver and called 911. EMS arrived on scene between 5-10 minutes from the initial call. EMS arrived and took over care for the resident. R1 expired at the facility. During visit, LPA interviewed the ED. Based on interview, ED confirmed the details of the report and stated R1 was given eggs, potatoes and sausages for breakfast. ED stated R1 does not have history of choking on food. LPA obtained records to include R1's physician's report, needs and services plan, hospice records, POLST, DNR, special diet board of memory care residents, and staff (S1) first aid certification . Based on record review, R1 was given a regular diet. R1 was able to feed self with no assistance required. R1's medical records did not indicate R1 required a special diet (ex: pureed or mechanical soft foods). The facility is pending the coroner's report. The facility will forward the Department R1's coroner's report and death certificate once obtained. No deficiencies are cited per California Code of Regulations, Title 22. This report was reviewed with Executive Director, Jett Cabuena and a copy of the report was provided.

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management - other visit. LPA met with Executive Director, Jairus "Jett" Cabuena. The purpose of the visit was to follow-up with a self reported SOC-341 that our Department received regarding inappropriate behavior staff had with resident(s) in care. During visit, LPA toured the Generations section with ED, also known as memory care. Residents were observed participating in activities with the supervision of multiple staff. LPA interviewed 4 staff (S1 - S4) members in Generations. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with, Executive Director, Jairus "Jett" Cabuena and a copy of the report was provided.

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility’s annual inspection focusing on infection control. LPA met with Executive Director, Jairus "Jett" Cabuena. During visit, LPA toured the facility with ED to include generations (memory care), 3 resident units in generations, assisted living, common dining rooms, activity rooms, bathrooms, and kitchen. All staff observed wearing a face covering. Facility temperature maintained between 68 - 84 degrees Fahrenheit. All fire exits were free and clear of obstruction. Facility has a designated entry point for symptom screening, temperature check, and sign-in. Hand sanitizer and face masks were available at entry. COVID-19 posters posted at the entry to include a required mask sign, symptoms of COVID, and visitation guidelines. Bathrooms supplies with hand washing sign, hygiene products, and paper supplies. Facility staff clean and disinfect multiple times daily and as needed. LPA observed the facility’s Personal Protective Equipment (PPE) supplies. Facility has procedures to isolation and testing for COVID-19. Staff are N95 fit tested. The following posters observed throughout the facility to include cough/sneeze etiquette, hand washing, proper ways to wear a face mask, and symptoms of COVID-19. No deficiencies were cited per California Code of Regulations, Title 22. Advisory note provided. See LIC9102. This report was reviewed with Executive Director, Jairus "Jett" Cabuena and a copy of the report was provided.

Based on interview, staff (S1) witnessed R1’s fall. S1 was wheeling R1 out of the shower room, when R1 grabbed onto the door frame and pulled themselves forward falling headfirst. S1 states to have never left R1 alone and was in proximity. S1 states to try grabbing onto R1’s shoulder to lean it back but was unable to react quickly enough to prevent the fall. S1 was aware of their procedures for a two-person assist for transfers, however, S1 believed showers and transporting from one room to another was a one-person assist. S1 states another staff helped transfer the resident to the wheelchair to shower. 2 staff were interviewed. 2 out of 2 staff believe the incident was not due to lack of supervision. 2 out of 2 staff state R1 requires a two-person assist for transfers to and from the wheelchair. Based on record review, R1’s signed service agreement only states a one-person assist for bathing. Other services such as dressing, grooming, and toileting only notes as “req assist” with no specific number of caregivers. R1 is a fall risk, and the facility notes actions to help reduce the risk of falls. The Department has investigated the above allegations. Based on interview and record review, the Department has determined that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No deficiencies are being cited per California Code of Regulations, Title 22. This report was reviewed with Executive Director (ED), Jairus “Jett” Cabuena and a copy of the report was provided.

Based on record review and interview, as of August 2022 the residents being investigated are no longer resides at the facility. Staff mismanages residents’ medications From 08/08/2022 – 08/11/2022, 5 out of 5 staff members were interviewed. 3 out of 5 staff members interviewed were familiar with medication management. 2 out of 5 staff members do not handle medications. 1 out of the 2 staff members does not provide direct resident care and was not asked questions regarding the allegation. 4 out of 4 staff have never observed staff pre-pour medications. 3 out of 4 staff have never observed medications on the floor. 1 out of 4 staff has observed medication on the floor. Staff state to follow the facility’s procedures after they observe medication on the floor. From 08/08/2022 – 12/01/2022, 5 out of 5 residents were interviewed. 4 out of 5 residents states to have never seen medications on the floor. 4 out of 5 residents state the staff has not mismanaged their medications. 1 out of 5 residents was not able to answer the interview questions. Staff handles residents in a rough manner From 08/08/2022 – 12/01/2022, 5 out of 5 residents were interviewed. 5 out of 5 residents state to have not been handled in a rough manner nor have staff forced them to do anything. 5 out of 5 residents stated positive feedback towards facility’s staff. Staff failed to follow residents’ prescribed diet plans On 08/08/2022, 5 out of 5 staff members were interviewed. 5 out of 5 staff members were not aware of staff failing to follow residents prescribed diet plans. Based on interviews, the facility has a dietary communication form that goes to the kitchen, which will show if the resident has a special diet. All food being given to the residents are prepared in the facility’s kitchen by the facility’s culinary service director. PAGE 2 OF 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 S3 state residents in memory care who have a special diet such as puree or mechanical soft will be indicated on a paper posted on the refrigerator. 1 out of 5 staff state to serve different kinds of alternative desserts for resident’s who are diabetic. The facility’s kitchen staff has a binder indicating every resident’s information to include special diet, allergies, etc. S4 states to know what kind of food is being served to the resident and ensure to do rounds to check if the residents are being served proper food. From 08/08/2022 to 12/01/2022, 5 out of 5 residents in were interviewed. 5 out of 5 residents does not have a special diet. 5 out of 5 residents are not given foods with too much sugar that would cause any medical concerns. Based on observation, the facility has a special diet board to include the residents name, picture, and type of special diet (puree or mechanical soft) posted on the refrigerator. Staff steals residents’ personal belongings On 08/08/2022, 5 out of 5 staff members were interviewed. 1 out of the 5 staff members does not provide direct resident care and was not asked questions regarding the allegation. 4 out of 4 staff members has not observed staff steal a resident’s personal belongings. Staff state sometimes the residents have behaviors of taking other resident’s personal belongings and placing them elsewhere. S2 state a staff member had to place a resident’s personal belongings in the facility’s activity closet due to behaviors to putting their clothing anywhere else but the resident’s room. From 08/08/2022 – 12/01/2022, 5 out of 5 residents were interviewed. 5 out of 5 residents have not observed staff steal their personal belongings. PAGE 3 OF 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 Based on observation, the facility’s Janitor closet contained items not limited to clothing, walkers, and diapers. S1 state the clothing in the janitor closet are from resident’s who have passed away, in which the family would like to donate. The diapers are for residents who have behaviors in tearing them apart, misplacing them, overstock, or are donated. LPA observed some items in the closet labeled with the resident’s name and room number, if they belong to a resident. The Department has investigated the above allegations. Based on interviews, records review, and observation the Department has determined that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No deficiencies are being cited per California Code of Regulations, Title 22. This report was reviewed with Executive Director, Jett Cabuena and a copy of the report was provided. PAGE 4 OF 4.

Licensing Program Analyst (LPA) Christine Dolores arrived at the facility unannounced to open an initial complaint investigation. LPA met with Resident Care Director (RCD), Julie Mayder. During complaint visit, a violation was observed and a case management - deficiencies visit was conducted. LPA toured the memory care section with RCD. At 01:44 p.m., LPA observed two out of two resident rooms who require oxygen, without a "No Smoking - Oxygen in use" sign posted in an appropriate area. HSD stated the signs were posted but sometimes the residents like to remove the signs from the wall. LPA advised to place the signs back on the walls. The facility staff corrected the violation during visit. At 03:45 p.m., , LPA observed the "Oxygen in use" sign posted in an appropriate area outside two out of two resident rooms. A technical violation was issued per California Code of Regulations, Title 22. No deficiencies were cited. This report was reviewed with Julie Mayder and a copy of the report was provided.

Licensing Program Analyst (LPA) Christine Dolores conducted an unannounced annual required inspection to focus on infection control. LPA met with Administrator, Diana Smith. During today's visit LPA toured the facility inside and outside. LPA observed the front entrance of the facility to include posters of required mask, feeling ill, symptoms of COVID-19, and CDC guidance for visitors proof of vaccination or proof of a negative COVID test. Facility has a central entry point and symptom screening area for all visitors and staff. Hand sanitizer is made available. All fire exit routes were free and clear of obstructions. Elevators observed to have signs for social distancing and required mask. Bathrooms observed to be supplied with hygiene products and paper supplies. Hand washing signs were posted in bathrooms and throughout facility. Foot operated trash can with lid observed in the bathrooms and throughout the facility. Assisted living dining room tables and chairs were spread apart to ensure social distancing. Social distancing signs was observed on each table. LPA observed facility to have enough PPE supplies. Facility disinfect and sanitize high touch surfaces daily and as needed. Facility has a mitigation plan in place to prevent the spread of COVID-19. All staff are N95 fit tested. No deficiencies cited during today's visit per California Code of Regulations, Title 22. This report was reviewed with Administrator, Diana Smith and a copy of this report was provided.

Licensing Program Analyst (LPA) Christine Dolores conducted a scheduled technical assistance visit and met with Executive Director, Jennifer Bruhn. During visit, LPA conducted a Facetime tour of the facility with PCC Toni Rivera and LPM Jackie Jin. The purpose of the visit was to provide technical assistance to prevent and mitigate the spread of COVID-19 at the facility. LPA, PCC, and LPM toured the facility to include the central entry point, screening area, assisted living (AL) dining room, AL private dining room, living room, bathrooms, and memory care (MC) to include the dining room, activity room, and common bathroom. All staff are N95 fit tested. During today's tele-visit, the following recommendations were made to the facility by PCC Toni Rivera: 1. Maintain a supply of disposable masks, gloves, and hand sanitizer accessible at the front desk for all visitors, staff, and residents 2. Place a 20 second hand-washing sign in all bathrooms 3. Maintain social distancing in all common areas to include the dining rooms 4. When 1 MedTech in MC is passing out medications , ensure staff first start with the negative residents and then move onto positive residents 5. Remove all common cloth rags and cloth towels. Use paper towels or disinfectant wipes to clean all surfaces 6. Maintain hand sanitizer in all PPE carts used for isolation rooms No deficiencies were cited as per California Code of Regulations, Title 22. This report was reviewed via telephone with Jennifer Bruhn and a copy of the report was emailed for signature.

Licensing Program Analyst (LPA) Christine Dolores and Licensing Program Manager (LPM) Jackie Jin conducted an unannounced case management visit to discuss an incident report submitted to CCL regarding a resident. LPA and LPM met with Sarah Serpa, Generations Program Director. It was reported that R1 was being help against his will and R1 made sexual advancements to staff. LPA and LPM interviewed Resident Care Director, Generation Program Director, and R1 regarding the incident. During interviews, facility staff and resident denied the incident that occurred at the facility. Resident Service Director and Generation Program Director created a plan of action that consist of communication with family and R1's physician regarding behavior and suggestion for a psychological evaluation. R1's medication will be given in the dining room and when staff is not comfortable in going into R1's apartment alone, they will ask another staff to accompany staff into apartment. LPA and LPM obtained a copy of R1's physician report, needs and services plan, and care notes. No deficiencies cited during today's visit. This report was reviewed with Sarah Serpa, Generation Program Director. Copy of this report provided.