Lake Park Senior Living

LPAs interviewed R1 who stated R1 has sufficient fund in R1's account and there's nothing showing R1 was charged by the bank for NSF. LPAs reviewed R1's bank statements which showed R1 issued check for 2 months rent for June 2024 and July 2024 and had an automatic payment deducted from R1's account on July 8, 2024. Lake Park returned the one month payment on July 3, 2024 and charged R1 for $50.00 for NSF. Based on interviews and records review, the preponderance of evidence is met, therefore, the allegation is unsubstantiated. An unsubstantiated findings mean that although the allegation may have happened or is valid there is not a preponderance of evidence that the violation occurred. No Deficiencies cited. Exit interview conducted. Copy of this report provided.

On 12/29/2024 at 12:50 PM, Licensing Program Analysts (LPA) David Doidge arrived unannounced to deliver an amended report for complaint 15-AS-20241030085123. LPA met with Executive Director, Kirsten Korfhage, and explained the purpose of the visit. LPA signed and printed the amended report. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

On 9/9/2022 at 10:30AM, Licensing Program Analysts (LPAs) K. Nguyen arrived unannounced to conduct Pre-licensing Inspection. Facility is currently licensed and pre-licensing is requested due to change of ownership. Upon arrival, LPAs met with Tammy Hauck Executive Director, and explained the purpose of the visit. LPAs toured facility with Executive Director including but not limited to random 7 residents’ room, common areas, multiple activity rooms, kitchen, laundry room, and first floor patio. Passageways and hallways are free of obstruction. Required posters are posted on the wall with Emergency Disaster Plan. A comfortable room temperature is maintained at 74 degrees Fahrenheit (F) in the lobby room. Each residents’ room is equipped with a heating and cooling unit. Refrigerator temperature is maintained at 30 degrees F and freezer temperature is maintained at 0 degrees F. Fire extinguisher was last serviced on 8/29/22. First Aid kit was complete. Carbon monoxide/smoke detectors were observed and interconnected with the sprinkler system Resident's room have nonskid mats and grab bars by the toilet and in the showers. All resident rooms have pull button that is centrally connected to the nurses station. No issues noted during inspection. LPAs observed that facility is ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed, and is subject to final approval by CAU. Additional requirements may still be required. Exit interview conducted and a copy of this report provided.

Continued from LIC9099 During interview with staff, LPA observed sufficient supplies in every department. Each department has a budget and uses Amazon Business to order supplies. Each department head has the task of ordering supplies on a monthly basis for the department he/she oversees. Orders are submitted and later approved by management, then supplies are delivered. If a department were to run low, or out of a supply, other departments will offer supplies until new supplies come in. Department heads also have access to a company credit card for emergency use. As long as staff go through the appropriate channels to order supplies, supplies get approved within a few days. Allegation: Staff are not adequately trained. Investigation Finding: Based on file review, training logs and staff interviews, this allegation is Unsubstantiated. Staff are adequately trained and detail logs of training are kept. Monthly all-staff meetings have different training provided. Staff are told in advance of when and what topics are going to be covered. Staff are also trained through Assisted Living Education (ALE) with records and certificates kept. Allegation: Staff are not following reporting requirements Investigation Finding: Based on staff interviews, death reports, and Unusual Incident Reports (UIRs) delivered to the department, this allegation is Unsubstantiated. Staff are required and encouraged to report any incidents and deaths to the Executive Director. Executive Director Kirsten Korfhage submits all reports to the department in a timely manner. LPA receives digital copies and the department retains copies. Allegation: Staff are not evaluating changes in resident's condition as required Investigation Finding: Based on record review and staff interviews, assessments of residents are being conducted. This allegation is Unsubstantiated. LPA reviewed and obtained copies of assessments for five (5) residents. Each resident had proper assessments. Previous record review from annual inspections also show resident assessments and evaluations were being conducted. 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 Continued from LIC9099-C Allegation: Staff do not address pest in the facility. Investigation Finding: Based on observation, staff interviews, and monthly statements form Clark Pest Control, this allegation is Unsubstantiated. LPA observed no signs of mold, rodent droppings or disrepair anywhere in the facility. The kitchen is clear of mold and other pests. Dishes are cleaned in a timely manner after use. Staff have admitted to finding cockroaches however, the facility has a contract with Clark Pest Control and all incidents are dealt with. Clark comes out on a weekly basis and treats any and all sightings of cockroaches reported. Allegation: Staff do not provide adequate food service. Investigation Finding: Based on interview with staff and staffing records, this allegation is Unsubstantiated. LPA observed food to be fresh and properly stored. LPA observed that there is sufficient staff for food service S4 reported that meal service may at times get backed up, but meals are still served with as limited delay as manageable. Allegation: Staff do not ensure the facility is properly maintained. Investigation Finding: Based on observation, staff interviews and Elevator Modernization Contract, this allegation is Unsubstantiated. LPA observed the Facility to be well maintained, with all areas kept clean, pest and mold free. Elevators have plans for modernization, with set repair dates. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations above do not meet Regulation Requirements are unsubstantiated. Exit interview conducted and a copy of this report provided.

Continued from LIC-9099 Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation above does not meet Regulation Requirements and is unsubstantiated . Allegation: Disaster drills are not being conducted as required. Findings: Based on record review, and staff interviews, LPA confirmed disaster drills are held monthly and logged appropriately. Therefore this allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation above does not meet Regulation Requirements and is unsubstantiated . Exit interview conducted and a copy of this report provided.

On 12/18/2024 at 11:45 PM, Licensing Program Analysts (LPA) David Doidge arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director, Kirsten Korfhage, and explained the purpose of the visit. LPA toured the facility including but not limit to, bedrooms, bathrooms, multiple activity rooms, kitchen, and common area. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 76.4 degrees Fahrenheit. The hot water temperature in a common bathroom was measured at 113 degrees Fahrenheit. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps are locked and inaccessible to residents in care. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 08/06/2025 Emergency disaster drills are conducted monthly, with the last one conducted on 12/02/2025. First aid kit was observed to be complete. LPA reviewed five (5) resident records and five (5) staff records, all were complete. No deficiencies observed or cited during this visit. Exit interview conducted and a copy of this report provided

Continued from LIC9099 Record review, and staff interviews confirmed no resident requires assistance with feeding, nor does any resident have a doctor ordered meal time. Therefore the above allegation is Un-Substantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations above do not meet Regulation Requirements are un-substantiated. Exit interview conducted and a copy of this report provided.

Continued from LIC9099 LPA interviewed two (2) residents (R1, R2) regarding the allegation. Both residents spoke about how elevator 1 had been closing on residents. Although the elevator was closing on residents, no injuries were reported by either resident. LPA also interviewed one (1) Staff (S1) in this matter. S1 reported to LPA that Metro Elevator is Lake Park's elevator repair company. S1 had placed a service call to Metro Elevator the day before due to concerns brought by residents. The Metro Elevator technician was on site repairing the elevator at time of interview with S1. LPA was able to observe the repair technician repair the sensor in the elevator and rode the elevator a few times to ensure it was functioning correctly. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation the facility’s elevator is in disrepair does not meet Regulation Requirements is un-substantiated. Exit interview conducted and a copy of this report provided.

Continued from LIC9099 Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation facility’s Disaster Plan does not meet Regulation Requirements is un-substantiated. Exit interview conducted and a copy of this report provided.

Continued from LIC9099 Elevator 2 stopped working early January. ED informed Otis, the elevator manufacture, and put in a service request. On February 3rd, Otis technicians repaired by installing the part and informed ED they would need to come back to put the elevator back in operation. The facility is waiting for Otis to come back out and finish the job. In the meantime, ED has been in contact with three (3) other repair companies to either repair or replace the current elevators. ED has documentation showing there is a not only a plan to repair the elevators, but a reasonable timeline for the repair has been established. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation the facility’s elevator is in disrepair does not meet Regulation Requirements is un-substantiated. Exit interview conducted and a copy of this report provided.

Continued from 9099 It was reported to the Department that the facility staff mismanaged resident’s medication. The department conducted interviews and reviewed R1’s MAR, medication count sheet, physician report, care plan, and medication staff communication log which revealed that R1 was provided PRN medication as (needed) prescribed. Medication was removed from the facility before LPA could verify count. Therefore, this allegation is Un-Substantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation Staff mismanaged resident's medication is un-substantiated.

Continued from LIC9099. dated August 9, 2023, that requested documentation from the facility for R1. There was another email on April 23, 2024, that involved the Ombudsman regarding documentation for R1’s responsible party, lastly LPA reviewed an email dated April 25, 2024, that indicated R1’s responsible party received documentation. Staff did not provide resident with privacy. Based on initial interview W1 stated the staff are disturbing and not providing the resident with privacy by constantly coming into the resident’s room. W2 stated during interview staff would barge in R1's room without knocking. Review of charting records from October 2023 to April 2024 indicated how many times staff come in R1’s room per day and what was done or said. LPA observed that on some days staff charted 10 different times staff would go to R1’s room. S6, S7, and S8 stated during interview that staff was instructed by S4 to go to R1’s room to do checks. S7 and S6 stated this is not done to all residents. Same staff stated R1 does not get as many checks now just a few reminders. Based on LPA observations, interviews which were conducted, and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted. A copy of the appeal rights and this report provided. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Continued from LIC9099. only staff person that was aware of this type of charting being done to another resident. W2 stated there were two (2) ex-employees told by S4 to get the level of care points up, which would increase the monthly service fee. Staff did not provide a comfortable environment for resident. Based on interview with W2 the facility was not welcoming and was a hostile environment. W2 recalled R1 being put in an elevator to go to the lobby and got lost in the basement. W2 felt this action was done intentionally. Based on review of preplacement appraisal dated 5/27/2023, R1 would not need any assistance moving around facility once fully acclimated to the new environment. LPAs spoke with two (2) residents during visit. Both R1 and R2 did not have any complaints about the facility or staff. LPAs observed both rooms were clean, and residents had their possessions. Staff did not assist resident with hygiene needs. During interview with witnesses both stated R1 did not want assistance with hygiene. W1 stated this allegation should not have been made and maybe there was a misunderstanding when reporting. W2 stated that R1 needed a reminder or help possibly once a day with toileting. Staff did not assist resident with laundry. During interview with witnesses both stated R1 did not want assistance with laundry. W1 stated this allegation should not have been made and maybe there was a misunderstanding when reporting. W2 stated the responsible party takes care of R1’s laundry. Continued on LIC9099C. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Continued from LIC9099C. Based upon the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and a copy of report was given .

LIC9099-C (Page 2) On 12/11/2024 LPA interviewed S4. S4 stated that per the Maintenance Director (MD) has confirmed that there was some plumbing work upgrades that were completed in the community regarding the ball valves in 2023. The work was planned with notices be distributed to all of the residents notifying them of the water shut for a period of time on the particular day. The MD explained that they did the A wing one day, drained all of the water, completed the work and turned the water back on. The next day same notices went out to the residents in the B wing and worked commenced the same as the day before. The MD said the work went smoothly with no complaints. S4 further stated that this work was preemptive so that if there was a need to shut off water during an emergency leak, the ball valves would be easier to close. The building had plug valves that were identified as old and needing replacement. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . No deficiencies cited during visit. Exit interview conducted and a copy of this report provided. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LIC9099-C (Page 2) On 02/21/2024 LPA interviewed S2. S2 stated that the facility had received 7-Day Notices from Pacific Gas & Electric Company (PG&E) and past due notices and Final Demand Notices from Waste Management. On 02/23/2024 LPA interviewed W1. W1 stated that they were contacted by Lake Park Senior Living in August 2023 for a sewer lateral repair. W1 stated that they presented a proposal for the project and was hired by Lake Park Senior Living to complete a two (2) phase project. W1 stated that they completed the first phase of replacing five (5) laterals which was invoiced for $42,800.00. W1 stated that the second phase proposal would be “pretty involved” and that they gave an estimated total of $179,410.00. W1 stated that they did not receive payment of $42,800 for the first phase and there was no further communication from management whether to proceed with the proposed second phase of the project. On 02/27/2024 LPA interviewed S1. S1 stated that another contract plumber was hired to replace twenty-seven (27) ball valves. S1 stated that the contractor invoiced on 09/22/2023 for $8,514.99 and that payments have not been paid. On 04/09/2024 LPA interviewed S1. S1 stated that two (2) of the residents (R1 and R2) had one-on-one care attendants in which were arranged by previous administration. S1 stated that the parent company, Pacifica, said that they did not approve the service and were not going to pay for caregiving services. S1 stated that they received a collection notice for non-payment from one of the resident’s caregiver agencies. S1 stated that the pest service, satellite television service was also disconnected for non-payments. LIC9099-C Continued... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LIC9099-C (Page 3) Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation are found to be SUBSTANTIATED . California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted. Appeal Rights and a copy of this report provided.

Continued from LIC9099 Per previous complaint filed on 4/2/24, Control Number 15-AS-20240402175048, with the allegation that the facility changed the plan of operation without CCLD approval, a copy of an admission agreement was obtained which did show that there was language pertaining to independent, general renters, aged 55 and older that was mixed with licensed RCFE language. Therefore, the allegation was previously investigated and substantiated on 7/25/24. The allegation for this complaint, Control Number 15-AS-20240701153826, is Substantiated, however no deficiencies are being issued on today’s date due to the previous Substantiation and Deficiencies cited on 7/25/24. Exit Interview conducted, and a copy of this report and appeal rights were provided. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Continued from LIC9099 Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation Staff mismanaged resident's medication is un-substantiated. Exit interview conducted. A copy of this report and appeal rights provided.

On this day at 11 am, a meeting was conducted by Assistant Program Administrator (APA) Stacy Barlow to verify Chapter 7 Bankruptcy Report filed by the Pacifica Senior Living as reported by the media. Present during the meeting are: Shelley Grace - Assistant Branch Chief, CCLD Craig Lundgren - Legal Counsel, CCLD Carl Knepler - Chief Executive Officer, Marlene Nelson - Director, Quality Assurance and Risk Management APA Barlow verified with Knepler information received by CCL from the media as follows: $25M lawsuit against the community located in Bakersfield Photography lawsuit against one of the properties lawsuit against a Skilled Nursing Facility (SNF) in the Healdsburg location Knepler states that despite the lawsuits, there is no financial impact to any of the properties, residents or staff of the company. Knepler added there are no vendor issues as well. continuation on Lic 809C 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 Knepler also states that management communicates with the staff and residents to make them aware of the changes. Signages have been changed. Knepler added that the bankruptcy did not affect any of the communities because Pacifica Senior Living Management was no longer the management company for any of the Pacifica Communities, that the communities had given notice to the department and residents back in October or November of last year of the changes in management companies. He said that the judgment in Bakersfield did not involve the operating entity, only the management company. He said there were no other suits pending against any of the Pacifica entities. APA requested the following documents be provided to CCL by today: Spread sheet of all facilities whose management company was/is Pacifica Senior Living Management Company management companies for each location letter provided to the residents notifying them of the changes At the conclusion of the meeting, APA emphasized to Knepler the importance of communicating with CCL any lawsuits that the company may have in the future. Knepler agreed with APA. A copy of this report was provided to Knepler.

continue from LIC 9099 The department conducted interviews and reviewed training documents which reveal that several staff are insufficient in required training's which provides knowledge and skills needed to provide the care and needs of the residents. Therefore, this allegation is Substantiated. Allegation: Facility has insufficient staffing Investigation Finding: Substantiated It was reported to the Department that the facility is short staffed during NOC shift. Review of staff schedules and interview with staff and residents revealed that there is 1 caregiver and 1 medication technician on staff during NOC shift. Interviews with residents also revealed that there are residents which require two persons transfer which would leave no staff available if staff had to attend to one of the other residents. Therefore, this allegation is Substantiated. Based on the Department’s investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED . California Code of Regulations, Title 22, are being cited on the attached LIC9099D. Exit interview conducted. A copy of this report and appeal rights provided. 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 Continue from LIC 9099 A The Department reviewed samples of resident’s files (7 out of 21 sampled), conducted interviews with staff and residents which revealed 1 resident out of the 7 with an expired re-appraisal. Therefore, this allegation is unsubstantiated. Allegation: Facility does not have a required Dietician Investigation Finding: unsubstantiated It was reported to the Department that the facility does not have a dietician as required for RCFE’s with a capacity of 50 or more residents. The Department conducted interviews and reviewed documents which revealed that the facility has a dietician on staff that signs off all menus and is available to residents if requested. Therefore, this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegations that the facility has not performed required annual re-appraisals and facility does not have a required dietician. Exit interview conducted. A copy of this report provided.

There's no additional information provided for the hatch construction and the elevator replacement plan. Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation are found to be SUBSTANTIATED . California Code of Regulations, Title 22, are being cited on the attached LIC9099D. Exit interview conducted. A copy of this report, civil penalty, and appeal rights provided.

On 2/5/2024 at approximately 10:00 AM, Licensing Program Analyst (LPA) J. Sampair conducted an unannounced initial 10-day complaint investigation. Upon entry, the LPA informed Executive Director (ED) Annemarie Domizio of the reason for the visit. During the visit, the LPA discovered that emergency drills were not being conducted and cited the facility for that (refer to 809-D for details). Exit interview conducted with Business Office Manager (BOM) Aryana Henry. A copy of this report provided via email.

On 12/04/2024 at 02:00 PM, Licensing Program Analysts (LPAs) D. Doidge and C. Fowler arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with, Executive Director, Kirsten Korfhage and explained the purpose of the visit. LPAs toured the facility including but not limit to, bedrooms, bathrooms, multiple activity rooms, kitchen, and common area. LPAs observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 72 degrees Fahrenheit. The hot water temperature in a common bathroom was measured at 112.2 degrees Fahrenheit. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps are locked and inaccessible to residents in care. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 08/12/2024. Emergency disaster drill was last conducted on 11/26/2024. First aid kit was observed to be complete. LPAs reviewed five (5) resident records and five (5) staff records, all were complete. No deficiencies observed or cited during this visit. . Exit interview conducted and a copy of this report provided

continued from LIC-9099 On 5/03/2024, LPA conducted an initial visit where they conducted interviews and record review. LPA reviewed R1’s Admissions Agreement, which indicated that R1 was admitted to the facility as an independent resident on 1/10/2018. LPA also reviewed physician reports, including a previous report from 12/6/2017 that stated R1 was fully independent, as well as a report dated 3/27/2024, which showed R1 had been diagnosed with dementia and experienced confusion and memory loss. During the investigation, LPA observed that R1 was initially in charge of their own affairs and had an emergency contact listed. However, through interview with previous ED and review of email correspondences LPA found that as concerns regarding R1’s cognitive decline arose, the previous ED contacted the emergency contact (W2) and R1’s Financial Advisor (W3) for guidance on 3/4/2024. The previous ED explained that, based on their observations of R1’s deteriorating condition, they reached out to W3 who is R1's financial advisor to express concerns about R1’s cognitive abilities and the potential risks to R1’s well-being. Previous ED was advised to contact R1’s attorney (W4) for POA information but previous ED never was able to reach W4 before they found out about the new POA. In the time while previous ED was trying to get in contact with W4, W2 took R1 to get a new physicians report. The previous ED stated that they followed the chain of contact, as outlined in R1's original documents, which specified the first emergency contact in case of concern. LPA reviewed and confirmed that based on R1’s emergency contact sheet the previous ED contacted the appropriate person. According to the original Emergency contact sheet W2 was designated as first person to be contacted for R1. The updated Emergency Contact sheet from 3/13/2024 still had W2 listed as the first point of contact for R1. Report continues on LIC-9099C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 continued from LIC-9099C The previous ED explained that after making the necessary contacts, including with R1's emergency contact W2 and financial advisor W3, an unrelated individual, referred to as W1, became involved and was designated as R1's medical POA on 3/8/2024. The previous ED expressed concern that this individual, who was not previously known to the facility or listed in R1’s documentation, could be potentially taking advantage of R1. The previous ED also contacted W2 3/14/2024 R1's emergency contact to discuss the situation further. Subsequently, R1 was taken for a medical evaluation on 3/27/2024, where it was confirmed that R1 had dementia and was unable to manage medications, leave unassisted, or access grooming items. LPA reviewed the visitor log for 3/8/2024, which showed that a notary signed in to visit R1, the same day W1 was listed the new POA, although there was no sign in for W1. The previous ED stated that their concern was that, due to the involvement of an individual who was not previously known to the facility and who was unrelated to R1, there was a potential risk of R1 being exploited. However, the previous ED adhered to the appropriate procedure by contacting R1’s emergency contact, as indicated in R1's original documentation, and did not interfere with the POA designation. Although there were concerns about R1’s cognitive decline and the involvement of an unknown individual, there is insufficient evidence to support the allegation that staff interfered with the designation of a responsible person for the resident. The previous ED followed the appropriate steps, as outlined by the documents approved by R1, and contacted the correct parties in response to the concerns raised. Therefore, the allegation of “staff interfering with the designation of a responsible person for the resident” is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

...Continued from LIC 9099 Although the allegations may have happened, or are valid, there is not a preponderance of evidence to prove them; therefore, the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided.

During investigation LPA obtained copies of resident roster, transportation planner in the month of May till present, and confirmation receipt from private company that facility call to arranged transportation to residents that are wheelchair bond. LPA interviewed residents that identify by activity director who are wheelchair bond. 2 out of 3 residents stated that facility staff do not transport them in the facility minivan nor the 14-passenger van, because there is no way our wheelchair can get in. LPA attempted to interview R1 but R1 didn’t want to be interview. LPA interviews staffs. 5 out of 5 staff stated that they have not transport any residents or have seen any staff that transport residents that are wheelchair bond on the mini-van nor the 14 passenger’s van. 5 out of 5 stated that residents that are wheelchair bond cannot get on to the mini-van or the 14 passenger’s van, because it’s impossible to get the wheelchair in for both van. S2 stated that S2 arranged all the transportation during the time that the main bus that transport wheelchair bond break down. S2 arranged transportation from residents who is wheelchair bond from their sister facility or the private company that specialized in transferring wheelchair bond. Based on information gathered, the allegation is closed as unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and copy of this report provided.

On 10/09/2024 at 4:00 PM Licensing Program Analysts (LPAs) L. Alexander and D. Doidge arrived unannounced to conduct a Case Management visit. LPAs met with Executive Director (ED), Kirsten Korfhage. While LPA L. Alexander and D. Doidge was conducting a complaint investigation (15-AS-20240811203347). LPA were informed back on 09/17/2024 that Northstar (management and Pacifica (ownership) did not have a surety bond. LPAs interviewed ED and asked if the facility holds the resident's cash. ED stated no and that residents may have a fiduciary or banker that manages their money. No deficiencies issued during the visit. Exit interview conducted and a copy of this report was provided.

Admission Agreement submitted to the Department which was approved upon granting of license was reviewed by LPA. Item C of the Admission Agreement under Basic Services indicated in part “ The Community will furnish the Apartment with carpeting and/or floor coverings, blinds, paint and/or wall covering on all interior walls and ceilings, convenience kitchen and/or kitchenette appliances, and heating and air conditioning. The Community shall have the sole and exclusive right to determine and select the type, style, design and color of each and every one of the foregoing items. Unless the Resident notifies the Community in writing of any alleged defect in the Apartment prior to the commencement of the Term, the Resident shall be deemed to have accepted the Apartment in an "as is'' condition.” The Admission Agreement also states under item E. Maintenance “The Community shall provide service and repairs for normal wear and tear to electrical and mechanical equipment provided with the Apartment. The Community will impose a charge to the Resident for the cost of replacement or repair of any such equipment that is caused by the Resident's neglect or willful act. Four (4) out of 5 residents interviewed stated there's refrigerator in their room/unit when they moved-in and didn't have problem with it, The other resident stated the refrigerator was not working when this resident moved-in but the staff replaced it immediately without charge. LPA inspected the refrigerators in the 5 residents' rooms/unit which were observed in operating condition. Based on information gathered, the allegation is closed as unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. ED left the facility and BOM stated she can sign and receive this report. Exit interview conducted, and copy of this report provided.

On 06/21/2024 at 3:00 PM Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a Case Management visit. LPA met with Executive Director, Kirsten Korfhage . While LPA L. Alexander was conducting a complaint investigation (15-AS-20240619101457) on 06/21/2024. LPA was informed that the food availability was questionable for the residents back on 05/26/2024. During the complaint visit, LPA observed that there was adequate food available. Therefore the food guest services is adequate for the residents. No deficiencies issued during the visit. Exit interview conducted and a copy of this report was provided.

On 4/11/2024 at 2:00PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a POC (Proof of Correction) visit. LPA met with Executive Director (ED), Annemarie Domizio, and informed the reason for the visit. LPA and ED went over the deficiency, the POC and the current billing and payment status for PG&E and Waste Management accounts. The following deficiencies were cleared by visit : 87755(b) - ED identified PG&E and Waste Management accounts are current and paid up through March 2024. Exit interview conducted. A copy of this report and Letter of Deficiency Citations Cleared provided.

On 3/28/2024 at 4:00 PM Licensing Program Analyst (LPA) Lori Alexander conducted an unannounced Case Management visit pertaining to information received by the Department indicating that the facility intends to rent units to independent 55+ individuals and persons with Section 8 Vouchers. The Department further received information indicating that the management company was told by the Licensee that those persons would not be subject to need for a Physician’s Report nor a Tuberculosis test. LPA met with Executive Director, Annemarie Domizio , for the purpose of gathering additional information. Documents obtained: Copy Lease Agreement for 55+ Copy Offer to Rent and Application Process Copy Pacifica S.D. Management Single Family Residence Rental Application No citations are being issued on this date. Exit interview conducted and a copy of this report provided.

On 04/09/2024 starting at 1:00 PM, Licensing Program Analyst (LPA) L. Alexander conducted a Case Management while at the facility for another matter. LPA met with Executive Director (ED), Annemarie Domizio, and explained the purpose of visit. During a complaint investigation (#15-AS-20240220153014) on 02/21/2024, LPA interviewed Staff and obtained the following documents: 1. Copy of invoices for non-payment for caregiver services 2. Copy of collection notice for caregiver services dated March 21, 2024 3. Copy of account ledgers for DIRECTV and Clark Pest Control 4. Copy of invoices for non-payment for DIRECTV and Clark Pest Control No citations are being issued on this date. Exit interview conducted and a copy of this report provided.

On 11/22/2024 at 9:50AM Licensing Program Analyst (LPA) A. Gomez conducted an unannounced Case Management visit. LPA met with Executive Director, Kirsten Korfhage and explained the purpose of the visit. While LPA was conducting a complaint investigation, #15-AS-20240503094454, on 5/03/2024, LPA observed during visit that the facility was not requiring visitors to sign in and allowing them to go up to residents apartments without signing in exposing them to their personal rights being violated by unknown persons. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.

...Report Continued from LIC9099 Allegation: Staff does not ensure facility restrooms have toiletries. LPA observed that the public restrooms used by facility residents did have toiletries. Allegation: Staff does not ensure facility restrooms are kept clean. LPA observed that the public restrooms used by facility residents did have toiletries. Although the allegations may have happened, or are valid, there is not a preponderance of evidence to prove them; therefore, the allegations are UNSUBSTANTIATED. Exit interview conducted with ED. Appeal Rights and a copy of this report provided via email.

... Report Continued from LIC9099 Allegation: Staff did not provide a safe environment for residents – Unsubstantiated On 2/2/2024 and 2/5/2024, the LPA interviewed Residents R1, R2, R3, and R5 who stated that their safety concerns were related to the lack of security guards (as addressed in the 3/10/2023 complaint that was substantiated on 2/1/2024) and the non-operational security doors at the front of the building and in the basement already cited in this complaint. During the LPA’s tours of the facility on 2/5/2024 and 2/9/2024, there were no other safety violations identified by the LPA. Although the allegations may have happened, or are valid, there is not a preponderance of evidence to prove them; therefore, the allegations are UNSUBSTANTIATED. Exit interview conducted with ED. Appeal Rights and a copy of this report provided via email.

On 03/28/2024 at 12:30 PM Licensing Program Analyst (LPA) Lori Alexander arrived unannounced to conduct a Case Management visit. LPA met with Executive Director, Annemarie Domizio. Pertaining to complaint 15-AS-2024 0220153014, LPA L. Alexander had on 2/21/24, 2/28/24, 2/29/24, 3/1/24, 3/11/24, 3/12/24, and 3/13/24 requested documents and information related to the payment history for all utility accounts, service vendors, the latest invoices/statements paid and the status of outstanding balances. To date, the facility has not provided an accounting of the services related to gas & electricity; and garbage/recycling/organic/bulky waste collection. Documents obtained: Resident Registry List dated 03/22/24 Copy of Synergy Bill Details from dates 09/28/23 thru 03/28/24 The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.

On 3/20/23 LPA KN interviewed S1 and S2, who denied having forced their way into R1s apartment. S1 stated that R1 had made an appointment to meet in R1s unit. When S1, accompanied by S2 arrived, R1 welcomed both staff persons into the unit. LPA KN spoke to R2, who also resides in the unit, and found that R2 was not present during the event, and had not heard anything pertaining to the allegation. No other potential witnesses were identified. No deficiency cited during visit. Exit interview conducted and a copy of this report provided via email.

...Report Continued from LIC9099 Allegation: Facility is in disrepair. – Unsubstantiated On 2/9/2024, the LPA interviewed Staff S1 about the amount of time that the shower was not available for residents during the renovation of the handicap accessible shower on the third floor. S1 stated that the time for the renovation was 4 days and that there had been no disruption in care for residents, as was verified by the entries in the shower log. Although the allegations may have happened, or are valid, there is not a preponderance of evidence to prove them; therefore, the allegations are UNSUBSTANTIATED. Exit interview conducted with ED. Appeal Rights and a copy of this report provided via email.

Allegation: Facility not providing security personnel per admission agreements – Substantiated On 3/20/2023 LPA KN obtained reviewed the CCRC contracts of residents admitted under the previous licensee, which indicated that the facility would provide 24 hour security guard service. LPA found that per the terms of the facility sale, the current licensee was to honor the existing CCRC contracts and Admission Agreements. LPA observed that the agreement generated under the previous Licensee provided that the Licensee “maintains a 24-hour emergency call system, a security entrance system, and security personnel. LPA interviewed R1 through R10 who stated that after the sale, the current Licensee terminated the guard service and assigned monitoring of the front door to staff employed directly by the facility who had other primary responsibilities (front desk staff). On 4/6/23 and 4/7/23, AGPA JW interviewed S1 through S4 and obtained an email communication between the facility and residents – which stated that the services of an outside Security Service were only in place until the Saturday/Sunday positions were filled and that front desk staff and additional personnel would provide security during working hours. R1 through R4 stated that there are times when no staff are near the entrance. LPA interviewed S1 who confirmed that the security service had been terminated. Report Continued on LIC 9099C... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation: Facility staff not accorded residents with dignity – Substantiated On 3/20/2023 LPA KN interviewed RP and R1 through R10 who stated that S1 does not treat them with dignity, with RP stating that S1 had yelled at them during council meetings. R1 further stated that the facility informed residents that it was not a Continuing Care Retirement Community, had threatened residents with higher charges and/or eviction if new agreements were not signed, and that the facility would not address their concerns regarding the facility’s CCRC status. R5 reported that S1 has lied to the residents when discussing the terms of the existing CCRC agreements that were to be adhered to, with S1 stating that there were no residents at the facility under CCRC agreements. On 3/20/23, LPA KN interviewed the Administrator, who stated that the facility is not a CCRC. Based upon resident and Administrator interviews the facility did not adhere to the H&SC code indicating that the residents shall have a right “to live in an environment that enhances personal dignity.” Report Continued on LIC 9099C... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation: Facility interfering with residents exercising rights – Substantiated On 3/20/23 LPA KN interviewed the RP who stated that R13 was informed by the facility that R13 would need to be moved from an Independent to an Assisted Living Unit, and was being required to sign a new Residence & Care Agreement. LPA observed that the original agreement generated under the previous licensee (and per the terms of the sale the current Licensee is required to adhere to original agreements) states that a new agreement was not required when transferring to Assisted Living. On the same date, LPA interviewed the Administrator who confirmed that R13 needed to be transferred and that a new agreement was required. LPA further found that R13 was moved from the Independent unit to a temporary Assisted Living unit due to refusal to sign a new agreement. This resulted in material misrepresentation made to a resident with an existing CCRC agreement. Deficiency is cited under the California Health and Safety Code listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted with, Business Office Manager Aryanna Henry. Appeal Rights and a copy of this report provided via email.

... Continued from LIC 9099 Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided.

On 03/28/2024 at 2:30 PM, Licensing Program Analyst (LPA) Lori Alexander conducted an unannounced Health and Safety check to address utilities are running, if there is any garbage build up anywhere on site, whether the facility is clean and how the residents are looking. LPA explained the purpose of the visit with Executive Director, Annemarie Domizio. During health and safety check, LPA observed a total of 3 staff members and 3 residents at facility. LPA toured facility with staff (S1), including but not limited to bedrooms, kitchen, bathroom, and common areas. Residents in care appear to be safe and there are no imminent health and safety concerns on today's date. Documents Obtained: Copy February 2024 Activity Calendar Copy Week 4 of Breakfast, Lunch and Dinner Menu No deficiencies cited during the Health and Safety check. Exit interview conducted and a copy of this report provided.

ED stated that printed monthly planned activities are distributed directly to the residents a week prior to the start of the month's activities so residents can look over the schedules and sign up in advance for outings or preferred events. LPA also observed additional hard copies of the monthly planned activities were readily accessible at the front desk for residents' use. ED showed a binder of the monthly activities for residents that is also left at the front desk for residents' perusal if desired. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff does not ensure planned activities are posted in a readily accessible location for residents and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff does not ensure planned activities are posted in a readily accessible location for residents is unsubstantiated. No deficiency cited during visit. Exit interview conducted and a copy of this report provided.

On 10/24/23 at 3:43PM, while at the facility for another reason, Licensing Program Analyst (LPA) toured the facility with executive director (ED) who stated that since the original structural and electrical configurations remained the same, no construction permits were required. ED shared a copy of facility sketch with LPA during visit (see 812 for details). ED stated that remodelled areas were sectioned off to ensure residents are not impacted by the renovations. ED stated they secured a permit for the new bathroom tiles (see 812 for more details). LPA observed new flooring, paint, furnitures and fixtures on the first, second and 12th floors. LPA observed facility to be clean, bright and in good repair. No deficiencies cited during inspection. Exit interview conducted and a copy of this report provided.

On 02/24/23 at 11AM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced case management health & safety check and met with executive director (ED). LPA explained the purpose of the visit with ED. LPA was screened at the front entrance with routine COVID-19 symptom checks done by staff. LPA toured the facility with ED. LPA observed facility is currently undergoing renovations in the library and visitation areas. LPA observed temporary wall erected in the hallway to ensure remodeling activities are contained within and residents are not impacted by the remodelling. ED stated the building is old and areas have been identified for renovations and improvements. LPA observed the kitchen had sufficient food supplies. Food supplies are ordered & delivered weekly. LPA also observed adequate supply of PPEs in the kitchen cabinets/storage areas. LPA observed bathrooms has sufficient soap and paper towel supplies. LPA observed dining area has been expanded to include a cafe area for breakfast and hot meals are served by staff in the dining hall for residents. ED stated residents have the option to have food to go or meal trays delivered to their respective apartments. Sufficient staffing was observed during visit. Pathways and hallways were observed free of obstruction and fire hazards. Comfortable temperature was maintained at 72 degrees Fahrenheit. LPA observed residents clean, well-groomed and comfortable in their surroundings. LPA obtained documents (current employee roster, assisted living staff schedule, housekeeping staff schedule, and maintenance staff schedule) during visit. Residents in care appear to be safe and there are no imminent health/safety concerns on today's date. No deficiencies cited during inspection. Exit interview conducted and a copy of this report provided.

On 2/6/23 starting at 1:55 p.m., Licensing Program Analyst (LPA) Catherine Lin arrived unannounced to conduct Post-Licensing inspection visit. LPA met with the new Administrator and disclosed the purpose of the visit. Upon entry, LPA’s temperature was checked by the staff, asked Covid-19 symptoms, and requested to wash hands with hand sanitizer. LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bathroom, kitchen, and common areas. There is one central entry point for universal screening for staff, residents, and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a sufficient 2-day perishable and one-week non-perishable food supply. Facility has 30-day supplies of gloves and N95 respirators. Facility has Mitigation Plan, Emergency Disaster Plan, and maintains record of routine screening for residents, staff, and visitors. No deficiency cited during visit. Exit interview conducted with Administrator, and a copy of this report provided.

On 12/21/2022 at 9:15AM, Licensing Program Analyst (LPA) C. Lin conducted an unannounced case management of health & safety check. LPA met with the Executive Director (ED) Candice Moses and explained the purpose of the visit. Upon entry, LPA walked through the facility with ED, Food, PPE, and emergency supplies are adequate, staffing is sufficient. Cough/sneeze etiquette and hand washing posters were observed posted in common areas and bathrooms. Staff was observed wearing surgical masks. Pathways and hallways were observed free of obstruction and fire hazards. LPA obtained staff schedules including assisted living, housekeepers and janitors, and maintenance staffing during visit. There was no imminent health/safety concerns on today's date. Exit interview conducted with ED and a copy of this report provided.

On 9/15/22 at 1:30 pm, a virtual meeting was conducted pertaining to the licensure (application pending) for Lake Park Senior Living and Pacific Grove Senior Living. Participants in the meeting included: Pam Gill, Assistant Program Administrator, CCLD Stacy Barlow, Assistant Program Administrator, CCLD Isaac Taggart, Regional Manager, CCLD Brenda White, Regional Manager, CCLD Jeremy Fong, Licensing Program Manager, CCLD Allison Nakatomi, Staff Services Manager for Continuing Care Retirement Care, CCLD Shawna Doucette, Licensing Program Analyst, CCLD Deepak Israni, President & Managing Partner, Pacifica Senior Living Carl Knepler, Senior Vice President of Operations, Pacifica Senior Living Marlene Nelson, Pacifica Senior Living John Peters, Northstar Tammy Hauck, Northstar CCLD reviewed the following expectations for Pacifica Senior Living and Northstar (hereinafter referred to as "applicants"): Identify an individual who will serve as Corporate Liason and be responsible for reviewing all licensing reports, report to the Board of Directors the status of corrections, and conduct quarterly quality assurance audits of both facilities. Ensure sufficient staffing at the facility to the extent that each memory care unit will be staffed independently, and that units do not share direct care staff. Ensure that the facility has adequate oversight by a qualified facility administrator during normal working hours at a minimum of 40 hours per week. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Assistant Program Administrator (APA) Pam Gill explained that the Department may conduct increased inspections for monitoring purposes. The applicant agreed to each of the listed conditions. A copy of this report was reviewed with Pacifica Senior Living and sent by email for signature. A fully signed copy of this report was provided to Pacifica Senior Living and placed into the facility file.