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It was also alleged that on 1/20/2026, witness #1 (W1) observed four (4) of eight (8) washing machines available for resident use had visible black/brown sludge on the interior rubber gaskets and two (2) others smelled unclean. On 2/17/2026, W1 observed two (2) washing machines available for resident use located on the south side of the second floor, finding significant debris and black/brown sludge on the interior rubber gaskets. On 3/10/2026, W1 observed a washing machine with black/brown sludge on the interior rubber gasket. On 4/2/2026, W1 observed the sludge on six (6) washing machines available for residents to use. The washing machines were not clean and sanitary, the machines are still not being maintained in an acceptable condition. LPA record review of resident council meeting notes revealed that during meetings conducted on 11/18/2025 and 1/20/2026 residents stated that washing machines had mold build up and that it smelled moldy inside. During a meeting conducted on 12/16/2025 residents mentioned a dirty tray that needed to be cleaned under a washing machine on the first floor, on 12/22/2025 the Administrator stated maintenance would take care of it, and during a resident council a meeting conducted on 1/20/2026 residents stated the same tray was still dirty. Review of maintenance logs revealed no record of requests submitted or action taken to resolve each of these concerns. Administrator states they were verbal requests from them directly to the Maintenance Director and they were addressed at that time. During today’s visit LPA, Administrator, and the Maintenance Director toured the facility observing all four (4) public use laundry rooms in the facility with a total of eight (8) front loading residential washing machines. LPA photographed all eight (8) of the washing machines, noting the two (2) located in the second floor south hallway to have a layer of removable residue and debris on the inside of the grey rubber gasket, under this layer was an additional dark brown/black layer of residue that was not easily removable. LPA noted multiple washing machine gaskets were clear of removable residue and debris close to the drain at the bottom but there was dry removable residue and debris toward the top half of the gaskets. Staff stated they were not aware the residue and debris got up there. Regarding the layer of residue difficult to remove, staff stated they have tried different methods to remove it without success; staff demonstrated to the LPA using a plastic brush that this lower layer of residue could not be removed with the brush. Staff also stated that the appliance service company recommends replacing the gasket as the best way to address this issue, but parts are difficult to find as these washing machines are approximately nine (9) years old. (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 eight (8) washing machines that are available for residents and found four (4) with visible black or brown sludge in the gaskets and two (2) others that smelled unclean. At the resident council meeting conducted on 2/17/2026, residents said the washing machines still smelled, the same day W1 checked two (2) machines on the second floor, south side, and found significant debris and black/brown sludge in the gaskets. On 3/10/2026, W1 observed a washing machine with black/brown sludge on the interior rubber gasket. On 4/2/2026, W1 checked the washing machines again and found unidentifiable sludge in the gaskets of six (6) machines. It is also alleged that facility Administration and staff have not addressed the residents' concerns in a timely manner. Five months after the residents first informed the administrator in writing that the washing machines were not clean and sanitary, the machines are still not being maintained in an acceptable condition. Interviews revealed that the members of the resident council submit their meeting notes, including concerns and recommendations, in writing to the Administrator. A review of resident council meeting notes revealed that during the resident council meeting held on 11/18/2025 regarding some of the washing machines on the second floor having mold inside the door and it was requested the machines be deep cleaned. In written response provided on 12/4/2025 the Administrator stated that a request to maintenance was entered to do a deep cleaning on the machines and it was expected to be completed soon. The maintenance log does not have record of this request being submitted. The Administrator stated that this request to maintenance was a verbal request to the Maintenance Director not a work order. Notes from a resident council meeting held on 12/16/2025 mention a suggestion box note stating that a washing machine on the first floor nearest to the bathrooms has a tray under it with standing water, dust and grime. In written response provided on 12/22/2025 the Administrator stated the maintenance department can address the first-floor machine and that the request was submitted the day of the response. The maintenance log does not have record of this request being submitted. The Administrator stated that this request to maintenance was a verbal request to the Maintenance Director not a work order. Resident council notes for a meeting conducted 1/20/2026 state that during an open discussion residents noted a moldy smell coming from the washing machines and that the tray under the machine on the first floor reported during the meeting held on 12/16/2025 is still dirty. (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 A response was provided by the Administrator on 1/22/2026 stating housekeepers use a disinfectant on the washing machines, part of the reason for the dirty tray is due to spillage when a detergent dispensing tube is moved to the machine detergent tray, because of this the tray under the machine gets dirty very quickly, maintenance does regularly clean them out, and because this detergent is for facility use only residents were asked to use their own detergent. Staff stated that they also determined this washing machine would continue to run water through the detergent tray causing it to overflow, water would run down the front of the machine into the tray, the company they use to service and repair their washing machines was called out and it was determined a faulty control board was the cause. An invoice from the appliance service company dated 1/16/2025 confirms service, labor and a new control board. LPA noted as of today’s visit the tray under the same washing machine on the first floor has standing liquid in it. Staff stated this tray has been cleaned during this time period. Interviews and records reveal that the Administrator responded to the written resident council concerns and recommendations within the required fourteen (14) calendar days. Although the Administrator responds within the required time it is noted that the concerns presented by residents regarding residue and moldy smells in the washing machines and a dirty tray under the one washer are ongoing issues since at least November 2025 and no routine measures have been taken to ensure the maintenance and cleanliness of these areas. Technical assistance was provided. Based on all interviews conducted, observation, and documents obtained, at this time the above allegation was found to be unsubstantiated, meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. 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 While touring LPA noted the washing machine on the first-floor south hallway with the tray under it to have standing liquid in it. Interviews revealed about a month ago this washing machine was malfunctioning running water through the detergent drawer for an extended period causing water to leak out into the tray; an appliance service company invoice shows these repairs were conducted on 1/16/2026. The Administrator states on another occasion two to three weeks ago in the first-floor laundry room the door on the same washing machine in the tray would not open, to release the door they had to empty the water that was in the washer, maintenance staff opened a plug underneath the washing machine causing water to shoot out past the tray and on to the laundry room floor causing the floor to warp and shift leaving two gaps less than one (1) inch by four (4) inches right in front of the washing machines. LPA documented the flooring issues also noting a white discoloration. Administrator stated there is no scheduled date to repair the floor but one of the maintenance staff should be able to. Staff interviews revealed that on a daily basis housekeeping staff wipe down the inside of the door and exterior of the washing machines; and approximately weekly they run a Tide washing machine cleaner on the clean cycle, but there is no schedule to clean the rubber gaskets, and that additional cleaning of the gaskets they think is required approximately every 2-4 weeks. These washing machines are used by residents in the independent/assisted living portion of the facility, housekeepers, and care staff. LPA toured the commercial laundry room outside of the entrance to Compass Rose, the memory care unit, to find two additional residential washing machines and a larger commercial washing machine; LPA noted one residential machine in use, the other residential and commercial machines to be free of residue and debris. Based on all interviews conducted, observation, and documents obtained, at this time the above allegation was found to be substantiated , there is a preponderance of the evidence to prove that the alleged violation occurred.

During the brief call, the Administrator stated that Community Care Licensing would be receiving an incident report regarding a new resident, R1, who eloped on 11/26/25 or 11/27/25; the Administrator was uncertain of the date. The Administrator stated the elopement occurred in the early morning hours and that R1 had made it up the driveway and was just onto the parking lot area of the apartments next door, which is not part of the facility property. LPA received a faxed LIC 624 Unusual Incident/Injury Report on 12/03/25. The Resident Services Director (RSD) was noted as the one who submitted the report, and it had the signature of the Administrator. Review of the incident report states R1 “set off [their] wanderguard pendant alarm while attempting to exit through the front doors of the community. Community staff immediately responded and intercepted the resident in the foyer between the double doors.” The incident report did not match what was discovered through the complaint investigation nor what was reported during the phone discussion by the Administrator. The investigation also revealed the facility called Emergency Medical Services (EMS) due to R1’s behaviors, hallucinations and refusal to return to R1’s room. LPA reviewed the electronic health record (eHR) for R1 for the date of the incident, which stated R1 “wanderguard pendant went off by room 137 door. Medication Technician…went to check door. Resident was seen outside of community.” Additional note stated “…spotted resident far away from the community in front of another building…” An image of room 137’s location next to the side door was taken by LPA on 12/08/25 to confirm the location was not near the “front door.” LPA obtained a copy of the EMS report, which states: “Per staff on scene, Pt was wandering outside of the facility.” This also contradicts the initial report that “Community staff immediately responded and intercepted the resident in the foyer between the double doors.” During the visit on 12/11/25, an interview with RSD was conducted for another open complaint, but during interview LPA inquired about elopement incident. RSD’s account matched the events noted in the eHR. LPA asked RSD to explain why their interview did not match the LIC 624 Unusual Incident Report sent to LPA on 12/3/25; RSD was unsure. Prior to leaving, the Administrator stated that the RSD admitted copying an updated narrative from their regional office into the incident report and did not review what the update was. (Continued on 9099-C) page 2 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 A revised LIC 624 incident report was completed and provided to LPA on 12/11/25. Review of this new report still has an inaccurate narrative which states the resident “exit through the front doors of the community. Community staff…intercepted the resident in the driveway of community…” Front door is often referenced to the lobby front doors, and the resident was not found in the driveway of the community. A review of R1’s Physician Report record indicated that as of the date of the elopement, R1 was not diagnosed with Dementia but with Mild Cognitive Impairment (MCI). Therefore, the regulations regarding elopement reporting would not apply regarding contacting Licensing within 24 hours, and the reporting requirements of providing a report within seven days would apply. The reporting within the appropriate timeframe was done. However, due to the misleading and inaccurate narrative of the original and revised incident reports received on 12/03/25 and 12/11/25, a citation for Title 22, Section 87211(a)(1)(D) is warranted. Based on interviews and record review, while an incident was reported in the correct time frame via a written LIC 624, the document provided did not correctly account for the “nature of the event” as required. The preponderance of evidence has been met; therefore, the allegation is SUBSTANTIATED. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D) An exit interview was conducted; deficiency cited; a copy of this report and the appeal rights was provided. 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 On 12/08/25, LPA requested and reviewed four (4) staff files related to open complaints; no concerns were identified at that time. On 12/11/25, during a separate complaint visit, the LPA conducted staff and management interviews. During these interviews, staff and management reported that a staff member had recently been terminated after being found asleep by a supervisor who arrived early to follow up on internal reports of the staff sleeping on shift. The LPA requested and reviewed the additional staff file and confirmed, through internal email documentation and a “Corrective Counseling Documentation” dated 12/3/25, that a staff member was observed sleeping at approximately 4:00 a.m. on 12/03/25 and was terminated effective the same date for violating facility policy. The investigation revealed other staff were still present on the shift and there was no evidence that residents’ needs were not met. Based on the information obtained through interviews and record review, the allegation regarding staff sleeping was found to have occurred; however, the facility conducted an internal investigation, promptly addressed the concern, and terminated the involved staff member on the same date the incident was confirmed. There was no evidence found to prove the residents were at risk. In addition, although an elopement incident did occur, available documentation shows the facility responded in a timely manner and took measures to address the situation. The facility demonstrated corrective action and implemented steps to mitigate potential risks to residents. Therefore, the preponderance of evidence does not exist to prove that the alleged violations occurred as reported, and the allegation is deemed UNSUBSTANTIATED. Allegation: Staff are not properly assessing the residents It was alleged that the administration is allowing residents to move in or live at the facility that are not fit for assisted living. The reporting party stated that Resident 2 (R2) “belongs in a skilled nursing home according to [their] home health nurse.” Interviews from staff and residents claim the facility is accepting residents that have more care needs than previously accepted into Assisted Living including more cognitive issues and residents who are less ambulatory and have higher care needs. LPA reviewed records on 12/8/25 for four residents including R2, all residents had their physician’s report, appraisal/needs and services plan, and functional capabilities assessments. LPA reviewed a sampling of six (6) resident files on 01/27/26, all of which had pre-admission appraisals and current appraisal/needs and services plan as well as re-assessments. There was no indication in any of the documents that any of these residents require 24-hour nursing care, and none of them had any prohibited health conditions. Continue 9099-C Page 2 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 LPA attempted to review one chef’s timecard; however, they were unavailable because the chef is salaried. The Administrator stated they were not aware of any issues with the chef’s start times. Interviews conducted during the prior complaint and a review of Resident Council minutes (Nov. 2025–Feb. 2026) reflected that breakfast generally runs smoothly Thursday through Monday, but Tuesdays and Wednesdays commonly have delays; however, residents did not attribute the delays to the chef’s arrival time during interviews. Based on observation, interviews, and record review, the allegation that residents lack access to food after the dining room is closed and that proper breakfast is not provided due to the chef’s attendance is UNSUBSTANTIATED. There was not a preponderance of evidence to demonstrate that these allegations are occurring. An exit interview was conducted; a copy of this report was provided. 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 Interviews with Administrator and RSD revealed they conduct pre-placement appraisals with residents and obtain functional capabilities assessments prior to admission, in accordance with regulations. Additionally, the facility’s policy states residents will have a reassessment 30 days after move-in, and every six months after, or when a change of condition occurs. Based on the record review, residents admitted to the facility do not violate regulations regarding allowable conditions, abilities, needs, and services. At this time, a preponderance of evidence does not exist to support that the alleged violations occurred as reported; therefore, the allegation is deemed UNSUBSTANTIATED. Allegation: Residents not being provided adequate food service. It was alleged that residents lack access to food after the dining room closes and that proper breakfast items are not provided due to the chef arriving late. Regarding food availability after dining room hours, on 4/1/26 LPA arrived at 7:45 a.m. to observe the bistro. LPA noted fruit, Jell O, yogurt, chips, cookies, and leftover desserts, with additional items such as sandwiches, bananas, and string cheese added after lunch. Residents interviewed reported that food is available, though popular items may run out quickly. LPA also observed the bistro stocked with food items during visits on 11/25/25, 12/11/25, and 1/27/26, and verified that items were replenished after lunch during each visit. Resident Council minutes from November 2025 through February 2026 reflected one discussion regarding the bistro running out of sandwiches, bananas, and coffee after breakfast. The com

The notice indicated the cause of eviction included behaviors by R1 that constituted “harassment or psychological abuse or causes mental suffering of an elder or dependent adult.” It was alleged if the behaviors rose to the level supporting an eviction notice, then the Administrator and staff, as mandated reporters, should have reported the abuse to Community Care Licensing (CCL), the local Long Term Care Ombudsman (LTCO) program, and local law enforcement using the SOC341 forms. Interviews conducted with residents indicated that R1 discouraged them from sitting with preferred companions, interfered with group participation, and was observed repeatedly raising their voice and talking rudely to staff. Two residents stated R1 repeatedly entered another resident’s apartment uninvited to complain, as this resident was the resident council president, but was on Hospice. Multiple residents reported avoiding dining and activities due to R1, some observed other residents crying after interactions with R1, and two residents stated they would move out if R1 remained. Resident Services Coordinator stated during interview R1 was overheard calling residents “dumb” or “not smart,” told some “you don’t belong,” and created a hostile environment. Staff interviewed stated they observed R1 yelling at residents and staff. On one occasion Staff 8 (S8) witnessed R1 throw a purse at a resident over a seating dispute on the bus. Staff noted residents with mild cognitive impairment were targeted and staff claim that some residents feared retaliation if they reported an incident and R1 found out about the report. LPA obtained facility forms titled “Resident/Family Grievance report”. Twenty-two (22) forms were collected, all regarding R1. Eleven (11) of the twenty-two (22) forms document events between 07/03/2024 and 03/09/2025 of R1 refusing seating or activity participation to other residents, repeated unwanted phone calls to Resident 10 (R10), loud/banging noises affecting neighboring residents, demeaning comments to staff, misuse of laundry machines causing disruption in other residents using them, and multiple resident/staff grievances. LPA received an Incident Report from 11/23/2024. The incident report documented a resident reporting to the facility that they were being harassed by R1, R1 was calling their cell phone repeatedly, and resident reported they felt very uncomfortable around R1 because they feel pressured or manipulated to join activities and meals. Continued 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 A letter dated 12/05/2024 was sent to LPA Rankin documenting instances of R1’s insulting and rude behavior to other residents causing them distress, rejecting residents from playing games, persistent unwanted phone calls to residents, loud noises in R1’s apartment, and screaming at staff. Additional documents collected include letter correspondence and an eviction notice for R1. A letter from 11/15/2024 documented verbal harassment of staff, screaming and insults; R1 was reminded harassment violates resident handbook. A letter from 11/28/2024 documented other residents feeling harassed, receiving unwanted attention, and feeling targeted; R1 was instructed harassment must cease and was warned against retaliation. A letter from 12/11/2024 documented turning away a resident from seating, rude conduct, persistent complaints; it was reiterated to R1 harassment was prohibited. A letter from 01/02/2025 noted harassment toward servers. R1’s eviction notice includes summaries of fifteen (15) instances where R1 verbally berated, yelled, and pressured or mistreated staff; and four (4) instances involving R1’s treatment of residents, which were corroborated by the interviews and grievance reports. Although a majority of the reported mistreatment was directed toward staff, residents were also present for some of these incidents and observed these interactions, which, according to interviews and grievances, created an environment of fear and psychological distress for residents, and disrupted their sense of safety and well-being. California Code of Regulations Title 22 87211(a)(1)(D) states the licensee must submit a written reporting to CCL within seven (7) days of “Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.” Mandated reporters must report abuse using form SOC341 per the definitions in Welfare and Institutions Code (WIC) §15610.07(a)(1) [“Abuse of an elder or a dependent adult” means any of the following: Physical abuse, neglect, abandonment, isolation, abduction, or other treatment with resulting…mental suffering.”] and WIC §15610.53 [“Mental suffering" means fear, agitation, confusion, severe depression, or other forms of serious emotional distress that is brought about by forms of intimidating behavior, threats, harassment, or by deceptive acts performed or false or misleading statements made with malicious intent to agitate, confuse, frighten, or cause severe depression or serious emotional distress of the elder or dependent adult.”] Continued 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 The evidence shows that R1’s behaviors constitute incident(s) that threaten the welfare and safety of residents and aligns with the definition of treatment resulting in mental suffering. The evidence demonstrates a pattern of psychological harassment by R1 toward staff and other residents, which negatively impacted the facility environment. Despite being aware of these effects, neither the Administrator nor staff submitted SOC341 reports to CCL, nor to LTCO or law enforcement as required per Welfare and Institutions Code (WIC) 15630. Based on interviews and documentation, there is a preponderance of evidence that the facility failed to meet mandated reporting requirements regarding suspected psychological abuse/mental suffering. Therefore, the allegation is substantiated at this time. This case will be cross-reported to California Department of Justice/Division of Medi-Cal Fraud and Elder Abuse (DOJ/DMFEA) and local law enforcement for failure to follow mandated reporter requirements. An exit interview was conducted, deficiency cited on 9099-D, a copy of this report and the appeal rights was provided.

On the allegation: Facility kitchen is dirty It was alleged that the facility kitchen is not being maintained in a clean and sanitary condition. During the visit, the LPA conducted a comprehensive tour of the kitchen and dining areas. The following observations were made: A shelf located above the food preparation and hot holding areas had a visible layer of grime. Items stored on this shelf (metal pots, strainers, and plastic containers) were placed upside down, with rims in contact with the surface. A light buildup of grease was observed on top of the oven. Minor food residue was noted under the oven and food prep shelving; however, this was consistent with normal daily kitchen use. All other areas of the kitchen—including the walk-in refrigerator, dry storage, prep counters, and general surfaces—were observed to be clean, well-organized, and maintained in a sanitary condition. While minor cleanliness issues were observed, they did not rise to the level of a systemic or ongoing sanitation concern. The overall condition of the kitchen and dining areas was found to be clean and well-maintained. Based on the limited scope of the observations and the absence of any immediate health or safety risk, the preponderance of evidence standard was not met. Therefore, the allegation is unsubstantiated . On the allegation: Facility has insufficient staff to meet the food service needs of the residents It was alleged that the facility has insufficient staffing to meet residents’ needs related to food preparation and dining room service. During the visit, the LPA observed breakfast and lunch service, conducted staff interviews, attended a discussion with the chef and residents, and reviewed resident council meeting minutes. Based on observations at the time of the visit, staffing levels in the kitchen and dining room during meal periods appeared to be adequate. Resident interviews and those who spoke during the discussion with the chef stated concerns regarding food not being served hot, wait times of 10–15 minutes to place an order, and overall service times ranging from 25 to 45 minutes. Continued 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 Staff interviews reflected mixed feedback. Some staff indicated that meal service runs more efficiently when specific cooks or team members are on duty, suggesting that individual performance impacts overall service quality. Consequently, there are periods when staffing and service delivery are sufficient, and other times when residents may experience delays. Discussions with lead staff, as well as observations of the dialogue between residents and the chef, indicate that the facility is actively working to improve communication, refine procedures, and streamline meal service operations. At this time, concerns regarding food temperature and service delays do not appear to be directly related to staffing levels, but rather to training and process inefficiencies. This was discussed with management during the visit. While the facility was found to be in compliance at the time of the visit, it is recommended that the facility continue to assess staffing patterns and enhance operational processes to ensure consistent and timely meal service. Based on observations and interviews, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur. Therefore, the allegation is UNSUBSTANTIATED . On the allegation: Facility failed to serve meals as planned and posted on the menu It was alleged that the facility does not consistently serve meals as listed on the posted weekly menus. During the visit, LPA reviewed facility menus, both those posted and the revised, "as served menus", interviewed residents and staff, and discussed the facility’s food service system. The facility utilizes a software system called Grove, which is designed to ensure meals meet regulatory nutritional standards and provides structured guidance for menu planning and substitutions. Title 22 regulations do not prohibit substitutions, provided menus are planned in advance, and maintained on file. Menus posted and copies are maintained on file as required. While some residents reported occasional substitutions or not knowing what would be served until arriving in the dining room, the investigation found that, substitutions were infrequent and generally comparable to the originally planned menu items. Per interviews the sides and deserts were the most common changes. Continued 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 However, for improved resident satisfaction, it is recommended that the facility enhance communication regarding menu changes—such as posting or announcing substitutions prior to meal service, whenever feasible. Based on a review of the regulation requirements and the facility being in compliance with applicable regulations regarding menu planning and nutritional offerings. This allegation is unsubstantiated at this time. Exit interview conducted, and a copy of this report issued. 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 In the walk-in refrigerator, the LPA initially observed an uncovered container of breakfast sausage links. Upon a second walkthrough, the container had been removed; however, an open, unsealed package of sausage patties was noted. All other food items in the walk-in appeared fresh, no odors or mold was observed and all were properly labeled and covered. In the dry storage room, five food items were found with expiration dates labeled “best by” or “use by” September 2025, indicating they were past their recommended shelf life. Additionally, two packages—one of spaghetti and one of cereal—had visible holes, with food spilling out. A container of raisins, not stored in its original packaging, was covered with plastic wrap that had a hole approximately the size of a quarter. Photographs were taken to document the observed items. These findings are not in compliance Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC9099-D). Section 87555(b)(28), which requires that All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery. Based on LPAs observations, the presence of expired and improperly stored food poses a potential health and safety risk to residents. The preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. Report discussed, and copies of appeal rights and reports printed.

Interview with the administrator and a director were done. Facility had reached out to the public health; first attempt was done on August 21st. Director stated they had been in contact with a public health Registered Nurse (RN), email provided shows that on Monday August 25th RN provided facility with basic information about the “Noro” (Norovirus). Email provided “specific cleaning suggestions.” LPA interviewed 8 residents in the assisted living side. While speaking with residents, 7 out of 8 stated that there have been no changes to schedules, dining processes, activities, and cleaning schedules. Residents interviewed were participating in bingo, sitting in the common halls, and in the dining room. All residents during discussion stated that this is where they usually sit, eat, or this is the activity they love to do. Allowing the LPA to understand that these common areas are part of their regular schedule. All residents stated none of their activities or day to day schedules have been changed over the past 2 – 3 weeks. LPA interviewed 10 staff, 7 of the staff work in the assisted living areas and 3 work in memory care unit. All staff stated that no changes to schedules have been made. 8 out of 10 staff stated that no changes to cleaning have been initiated, no extra cleaning requested, all stated it has been the same schedule and process as usual for the past 2 weeks. The two staff who stated that cleaning was increased were in the kitchen area and stated that cleaning to chair handrails and tables had increased starting around the 25th through the weekend of the 30th. While the residents and staff did adhere to isolating residents with symptoms, and as of today the illness was contained and only 7 – 9 residents had displayed symptoms, and one tested positive for a contagious disease, based on interviews and provided documents, the facility did not comply with the regulations 87470 Infection Control Requirements “(b) In addition to subsection (a), when one or more residents in the facility are diagnosed with a contagious disease, the following shall apply: (1) In addition to the requirements of subsection (a)(2), assigned staff …regardless of having direct contact with residents, shall be required to perform enhanced environmental cleaning and disinfection to maintain a safe and sanitary environment and to prevent, contain, and mitigate the transmission of the contagious disease.” the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. Copy of report printed along with copy of appeal rights. 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 the allegation: Facility failed to follow reporting requirements On August 21st at 8:51am the administrator contacted LPA to inform LPA of a possible outbreak, with symptoms of vomiting and diarrhea. The administrator included in correspondence that the county had been called, and he was waiting for a call back. The requirement of reporting possible outbreak to Community Care Licensing was done as required. When a positive test was done on August 27th to show the outbreak was Norovirus, there was only one resident symptomatic, and no additional cases occurred after that. LPA and administrator discussed that any future concerns, the same notification will be made to initiate the concern of a possible outbreak, and communication stating a positive test result has been received will be provided to licensing, even if it is only one case. Based on interviews conducted, and record reviews, at this time the preponderance of evidence standard has not been met; therefore, the above allegation is found to be UNSUBSTANTIATED. Exit interview conducted and copy of report provided to administrator.

The facility ruled unsanitary living conditions and the Fire Chief deemed the room a bio hazard, A bio hazard cleaning crew was brought in to remove the bio hazard and clean the room. Resident 1 (R1) was issued an eviction on 05/30/2024 with the following dates of noncompliance to keep room clean and free from odors 11/15/2023, 12/11/2023, 02/06/2024, 02/29/2024, 03/21/2024, 03/24/2024, 04/29/2024 along with multiple other dates ranging from 02/24/2024-03/19/2024 with refusals of care needs, room cleaning, and laundry services. Based on the evidence this allegation is deemed Substantiated at this time. On the allegation: Facility staffing is not sufficient in dining to meet the needs of the residents. LPA interviewed staff and residents which revealed the dining room staffing is getting better but still short a few positions, dishwasher, busser and server. Staff stay late or staff come in early when they can. The staff call offs are what make the dining room short staffed when no one can cover the shift. Staff have had to work shorthanded, and the wait times can increase for residents. Staff stated you can’t look at the schedule because it does not reflect for call offs or no shows so you really can’t tell if the kitchen is short staffed by looking at the schedules. Facility census was 98 residents on 08/24/2023. LPA emailed Administrator on 08/29/2023 and asked what it looks like if the kitchen and dining are fully staffed. Administrator stated 1 AM cook, 2 AM servers, at 11:00am the PM staff of 1 dishwasher and 1 additional server come in for lunch and the PM service, 1 PM cook and 1-2 more servers for dinner. LPA De Leon reviewed the staff schedules for 12/01/2023-12/11/2023 for kitchen/dining staff. The facility census was 108 residents on 1/11/2023. On 12/02/2023 the facility was short 1 am server, on 12/03/2023 the facility was short staffed 1 am server, on 12/04/2023 the facility was short staffed 1 am server, on 12/05/2023 the kitchen was short staffed 1 cook in the pm, on 12/10/2023 the kitchen was short 1 am server, and on 12/11/2023 the kitchen was short staffed 1 am server. Staff stated the Food Service Director/ Chef does help cover positions when the facility is short staffed but not all the time. Based on the evidence this allegation is deemed Substantiated at this time. Exit interview conducted, copy of report and appeal rights printed for Administrator.

LPA De Leon conducted a subsequent visit to the facility on 08/23/2023. LPA collected additional records: staff schedules, resident roster and staff schedules for August 2023, Staff disciplinary records for 2023, and Call pendant logs. LPA conducted interviews with staff at 10:15am, 11:10am, 11:50am, 12:05pm, 1:05pm, 1:20pm, 1:40pm, 2:20pm, 3:30pm, and 4:15pm. LPA interviewed residents at 12:15pm, 12:30pm, 12:45pm, and 2:55pm. LPA De Leon conducted additional staff interviews on 08/24/2023 at 11:18am and resident interviews at 12:20pm, 12:40pm, 1:45pm, 2:12pm, 3:15pm, 5:00pm, and 5:05pm. On the allegation: Facility staff handles residents in a rough manner resulting in skin tears. LPA interviewed staff which revealed 3 staff felt S1 handled residents in a rough manner and several residents told staff that they did not want assistance from S1. LPA reviewed disciplinary records for S1 which revealed S1 had a corrective counseling documentation dated 01/10/2023 where a peer reported S1’s approach with residents was a concern, S1 could be intimidating in size and tone of voice. The facility had a documented discussion with S1 for prohibited conduct -Caring for resident in an unprofessional manner and speaking to a resident in an unprofessional or discourteous manner, S1 was re-trained in customer service, dementia care, and proper re-directing techniques. On 02/21/2023 an internal investigation was conducted by the facility from 02/21/2023-02/24/2023 for allegation of elder abuse by S1. S1 was put on leave 02/21/2023 and was terminated based on the investigation and interviews from residents and staff for a violation of policy- prohibited conduct as of 2:45pm on 02/24/2023. Based on the evidence this allegation is deemed Substantiated at this time. On the allegation: Facility staff using profanity towards residents. LPA reviewed records for S1 due to an internal investigation on 02/21/2023 conducted by the facility from 02/21/2023-02/24/2023 for allegation of elder abuse by S1. S1 admitted to using profanity when discussing a resident or care related conversations with other staff. Staff interview revealed staff heard S1 use profanity in front of residents. Based on the evidence this allegation is Substantiated. On the allegation: Facility staff does not wear gloves when preparing food. LPA De Leon interviewed staff which revealed staff 2 (S2) does not wear gloves when preparing food in the kitchen. Disciplinary records were reviewed on S2, S2 no longer works at the facility, and S2 was let go for other reasons. Based on the evidence this allegation is Substantiated . Exit interview conducted, deficiencies cited, copy of report and appeal rights printed for Administrator. 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 LPA De Leon conducted a subsequent visit to the facility on 08/23/2023. LPA collected additional records: staff schedules, resident roster and staff schedules for August 2023, Staff disciplinary records for 2023, and Call pendant logs. LPA conducted interviews with staff at 10:15am, 11:10am, 11:50am, 12:05pm, 1:05pm, 1:20pm, 1:40pm, 2:20pm, 3:30pm, and 4:15pm. LPA interviewed residents at 12:15pm, 12:30pm, 12:45pm, and 2:55pm. LPA De Leon conducted additional staff interviews on 08/24/2023 at 11:18am and resident interviews at 12:20pm, 12:40pm, 1:45pm, 2:12pm, 3:15pm, 5:00pm, and 5:05pm. On the allegation: Facility staff did not properly store food causing residents to have food poisoning. LPA conducted interviews with staff and residents which revealed some residents got sick from a meal served by the facility in 01/2023. The interviews conducted do no mention anything about food storage or food poisoning. The facility did not have any incident reports of food poisoning and none of the residents went to the ER for any type of food poisoning. LPA conducted unannounced visits on 01/20/2023 and toured the kitchen, all food was stored properly. LPA found no evidence to support food poisoning or improper storage of food by facility staff. Due to the lack of evidence to support this allegation it is deemed Unsubstantiated. On the allegation: Facility staff threatened to evict resident. LPA interviewed staff and residents which revealed no residents were threatened with eviction. According to staff interview a resident said a physical therapist not an employee of the facility told a resident that they needed to do the required physical therapy or could risk eviction if the resident didn’t do the rehab. Another staff said the physical therapist is stern to the clients about rehab and some residents do not like to hear it. Based on the evidence this was not a facility staff therefore the allegation is deemed Unsubstantiated at this time. On the allegation: Facility kitchen is dirty. LPA De Leon conducted an unannounced visit on 01/20/2023, toured the facility Commercial kitchen and did not find it to be dirty. LPA conducted interviews with 15/16 staff which revealed staff did not think the kitchen was dirty. Resident interviews revealed 11/11 had not seen the inside of the kitchen, but a resident reported that other residents had and those residents were impressed with the kitchen, so the resident would not think it would dirty, if other residents were impressed. LPA reviewed schedules for kitchen staff with job duties which revealed the kitchen could be short staffed at times. It was stated in interviews that when short staffed if something did not get done on a staffs shift, it was done by staff on the next shift. Due to the lack of evidence this allegation is deemed Unsubstantiated ay this time. Exit interview conducted and copy of report printed for Administrator.

On the allegation: Staff do not assist residents with showering. LPA conducted interviews with 15 random staff and 12 random residents. Resident interviews revealed 5 out of 12 residents has issues with showers being rescheduled due to a lack of staffing available on their scheduled shower date and time. Staff interviews revealed 8 out of 15 staff said when the facility works short staffed with 2 caregivers or less showers run late, get rescheduled or when staff is available residents no longer want to take the shower. R1 has had 25 missed showers due to one of the shower days being Sunday on the PM shift and staff was not available to help assist R1 with showers. R1 pays for a care plan with two shower days per month with assistance. R1 had brought up the missed showers with the Nurse and the Administrator at that time and they had agreed to give coupons for guest dining to make up for the missed showers. R1 wanted dollar for dollar in coupons for the missed showers. R1 stated as of 08/24/2023 R1 had not been reimbursed for the missed showers as the facility had decided they were not going to give coupons for guest meals to reimburse R1 for the 25 missed showers on the dollar-for-dollar bases. R1 was still waiting for the facility to decide how to refund R1 for the missed showers. Staff interviews revealed that when the facility has 3 caregivers on the floor all the showers can be completed but when it goes down to 2 caregivers on the floor it gets harder to complete all the daily tasks and when 1 caregiver is on the floor alone several daily tasks can not get completed. Based on the evidence this allegation is Substantiated at this time. On the allegation: Staff do not answer residents' pendants in a timely manner. LPA interviewed with 8 out of 15 staff which revealed that if the facility is fully staffed, they can answer the residents’ pendants in 10 minutes or less. Staff had recently reported staff meetings where the pendants calls were reviewed with expectation on staff answering calls in 5-10 minutes. Staff stated if they have 3 caregivers on the floor they are able to meet all residents needs timely but when the facility has call offs and they become short staffed with 2 caregivers, they can work extra hard and still able to get most of the assigned duties completed, it is when the facility is short staffed with 1 care giver on the floor staff stated it is impossible to get all assigned tasks completed in a timely manner. LPA conducted interviews with 5 out of 12 residents which revealed when pushing the pendant, it took longer than 10 plus minutes to get staff assistance, at times staff took 30 plus minutes to assist, or staff did not come at all. Continued 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 LPA reviewed another 11 randomly chosen residents from the facilities resident roster to review call pendants logs from 12/01/2022-12/13/2022. The logs revealed 8 out of the 11 residents had pendants calls with waiting times of over 11-30 minutes long. Residents Pendant Logs revealed: One resident had 12 calls during this time period of 12/01/2022-12/12/2022 that were in excess of 10 plus minutes 11 min, 12 min, 2-13min, 14min, 16 min, 17 min, 21 min, 27 min, 3-30 minutes. Another resident had 11 calls during the same time period ranging from 11 minutes to 30 minutes. Another resident had 5 calls during this same time period ranging from 11 minutes to 30 minutes. Another resident had 13 calls during this same time period ranging from 15 minutes to 30 minutes. A shared apartment had 2 calls over 19 and 20 minutes during the same time period. Another resident shows 3 calls ranging in 11-30 minutes. Another resident reviewed had 29 calls ranging from 11 minutes to 30 minutes. The remaining 3 residents did not have any calls over 10 minutes. Based on the evidence this allegation is Substantiated at this time. Exit interview conducted, deficiencies cited, copy of report and appeal rights printed for Staff and emailed copy to Administrator. 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 the allegation: Staff do not meet residents' incontinence needs. LPA interviewed staff and residents which revealed residents with incontinence care plans are conducted with rounds every 2 hours for staff to assist residents. Residents have call pendants and pull cords to use if assistance is needed at any other time. Call pendants are answered in order and according to needs of the residents. Some resident interviews stated some of the calls are not answered timely. Staff interviews revealed even when working short staffed on shift the incontinence needs of the residents are always taken care of on rounds, a few residents can be wet when checking on rounds, but all residents are checked and changed, residents are neglected, no residents have rashes or sores to indicate incontinence needs are not being met. Based on the lack of evidence this allegation is deemed Unsubstantiated at this time. On the allegation: Staff do not properly supervise residents. The facility is an assisted living with a memory care unit on the premises serving senior residents that have added care plans based on the need of each resident. Assisted Living residents and Memory care residents have round -the -clock caregivers and medication technicians (Med-Tech) available by pendant or pull cords for assistance. The assisted living residents have the capability to call the front desk for non-urgent matters as well as call 911 for any urgent medical matters. The residents that have added supervision due to incontinence or memory care issues have 2-hour rounds conducted by the care giving staff to help. Some residents have added care plans for assistance with daily living for bathing, dressing, transfers, and 2-person assist. Residents interviewed did not have any concerns with supervision. Based on the lack of evidence this allegation is deemed Unsubstantiated at this time. Exit interview conducted and copy of report printed for staff and emailed to Administrator.

Three of three Staff members stated that the main kitchen brings a cart with hot food. The prepared food is kept in a steam table and then plated for residents. At the end of each meal, leftover plates are wrapped and labeled with the time, date and name of resident. Staff stated that lunch plates can be left out on the counter for up to one hour, then placed in the refrigerator and then tossed in trash by 2:00 p.m. Staff stated that expired foods are tossed out and Staff always reviews the expiration date before serving residents. Staff has never observed moldy food in refrigerator, including moldy juice boxes. Staff 1 stated that the Director of Kitchen, ensures that food supplies like hot chocolate and cereal are well stocked and checks for expired foods. Staff serves dinner at 5:00 p.m. Staff stated that wrapped plates can sit on a counter until 7:00 p.m. but is thrown away and not served to residents. Staff observed expired food in the refrigerator about a year ago. Staff further stated that resident family members often bring food and place in the refrigerator with their name and room number. Staff is not aware of anyone from main kitchen checking the refrigerator for expired foods. However, main kitchen staff stocks the refrigerator and cleans the kitchen. Staff stated that in the event a resident does not eat dinner, the plate is wrapped, labeled and may remain on the counter top unrefrigerated as late as 10:30 p.m. Staff stated that this occurs three times a week. Staff has offered these plates to night shift staff and if they are not eaten by staff, they dispose of food in trash. Kitchen Staff typically stock and dispose of expired foods. Staff stated that there have been occasions when juice has been expired and he has had to dispose of item. In one instance there was an opened bottle of juice that had been sitting for more than a month. Staff reminds staff to be vigilant and notifies a supervisor that he has disposed of the item. Staff is not aware of a scheduled date to go through the refrigerator and check for expired foods. Based on the information obtained, the allegation is deemed Substantiated at this time. 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 door under the sink is typically locked but the locking mechanism is lose and onsite maintenance will repair it February 9, 2024. Nothing under the sink is a danger to residents, but glass vases will be moved to a locked storage closet. The memory care director further advised that resident was hoarding forks and spoons, as such, the kitchen implemented a magnetic silverware catcher. The equipment was washed weekly and effective February 7, 2024, the equipment is washed daily. Three of three staff has no knowledge of a trap under sink and has no knowledge of any rodent issues. There was an issue with ants during the recent rainstorms and pest control came in last week to resolve it. Staff stated that small frogs and crickets enter the building from under the exit door and dining room door, during rainstorms. Staff stated that the magnetic silverware catcher was procured within the last four months and is cleaned weekly. Staff stated it will be cleaned more often. The cabinet under the kitchen sink has not been locked because chemicals are no longer kept in that location. Staff stated that they cleaned the magnetic silverware catcher on one occasion and has advised staff to clean it. Staff stated that the equipment is cleaned daily but it is very hard to get very clean. Staff stated that the magnetic silverware catcher is always dirty and is not sure how often it is cleaned. Based on the information obtained, the allegation is deemed Unsubstantiated at this time.