Oakland Heights Senior Living

On 04/06/2026 at 12:00 PM, Licensing Program Analyst (LPA) P. Manalo conducted a Health & Safety inspection as a result of a priority 2 complaint. LPA met with Executive Director, Anthony Garcia and explained the purpose of the visit. LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, and outdoor area. Hot water temperature was measured at 100.1, 104, 106, and 120 degrees Fahrenheit in the hallway bathrooms and/or resident bathrooms. There are 7-days of non-perishable and 2-day of perishable food supplies were sufficient. Facility orders food supplies twice a week. Carbon monoxide detectors were observed in operating condition. Smoke/ Fire Alarm is undergoing repairs and reinstallation by vendors Bay Alarm. First-aid kit was complete. Fire extinguisher was last serviced on 04/24/2025 and 04/01/2026 all around the facility. Liability Insurance is effective from 10/01/2025 to 10/01/2026. 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 with Executive Director. Appeal Rights and a copy of this report provided.

Continued from LIC9099 When the pendant is pressed, an alert will prompt on three monitors spaced throughout the facility. The alert shows who is calling for help and where the resident is calling from. Staff respond to the alert and touch their ID badge to the pendent to clear the alert. S2 demonstrated to LPA how the pendants alert and operate. The pendent will flash yellow when pressed to indicate a low battery, and the resident is instructed to inform staff when the battery gets low. S3 informed LPA that although the signal system will show on the monitor if a battery is getting low, but it is not full proof, and residents in Independent Living are instructed and reminded to inform staff when the battery gets low so staff can change out the battery. S3 reported that R1 was given a pendent with instructions on how to operate and check the battery, however R1 had never informed staff of a low battery nor brought the pendent in for staff to look over. Residents in Assisted Living have their pendent batteries checked by care givers periodically. R2 informed LPA R2 does not like to wear the pendent and never checks it. R2 did tell LPA that R2 was shown how it operates and instructed to inform staff of a low battery or have staff look it over to ensure it is functioning. R2 is in Independent Living. Since R1 had not altered staff to the battery in the pendent being dead, nor did R1 ever have staff inspect the pendent since it was given to R1, staff had no way to ensure the pendent was functioning or not, therefore the allegation is UNSUBSTANTIATED. Allegation: Staff did not answer resident's calls for assistance timely Investigation Findings: It was reported to the department that the facility did not answer the resident’s call for assistance timely. The facility had issued a wearable emergency fob to R1 that did not function resulting in another resident having to seek assistance for R1. LPA spoke with R3, the resident that sought help for R1. R3 heard R1 fall, walked into the kitchen and saw R1 on the floor. R1 told R3 that R1 pressed the pendent, but it did not light up to indicate it made the call. R1 then asked R3 to call for help. R3 walked out of the apartment and to the front desk of the facility and asked S3 to call 911. S3 called 911, EMTs responded promptly. S3 also informed caregivers in the facility that R1 had fallen, and caregivers went to the room to assist. R3 reported staff acted immediately when informed of the fall, therefore the allegation of Staff did not answer resident’s calls for assistance timely is UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided.

On 2/25/2026 at 3:00PM, Licensing Program Analysts (LPAs) G. Luk and K. Nguyen arrived unannounced to conduct a case management visit to follow up facility’s inclusion of a Bed Bug Addendum in resident’s admission agreement. LPAs met with Executive Director, Anthony Garcia and informed him the reason for the visit. LPAs reviewed the facility’s current admission agreement/contract dated 1/9/2026. This includes Appendix J Bed Bug Addendum which reads, “As such, you shall be responsible for any damages incurred by us as a result of such infestation, including but not limited to the cost of treatment for the Community and any surrounding units as recommended by a qualified and licensed pest control company…” Per regulation 87468.1(a)(2), resident shall be “...accorded safe, healthful and comfortable accommodations, furnishings and equipment.” Additionally, under regulation 87303(a), “the facility shall be clean, safe, sanitary and in good repair at all times.” Therefore, it is the facility’s responsibility to ensure residents are provided with safe, healthful, and comfortable accommodations which includes bed bug eradication. The cost cannot be transferred to the residents in care. An admission agreement shall not contain any written or oral agreements to waive facility responsibility for 'the provision of safe and healthful facilities, equipment and accommodations.' The deficiency was observed (see LIC 809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.

S2 stated that she reported the outbreak to public health on 7/11/25 via phone and followed up with an email on 7/15/25. LPA reviewed the email documentation 7/15/25. Interviews with residents revealed that 4 of the 5 affected residents live in the independent side of the facility and as such do not receive any care. All 4 reported that when they started feeling symptoms they sought care from their physicians and once diagnosed they reported it to the facility. LPAs attempted to interview R5’s conservator but was unable to reach her. This agency has investigated the complaint alleging facility staff are not properly addressing pests in the facility. We have found that the complaint was 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 . Exit interview conducted, a copy of this report provided.

Allegation: Staff did not keep the facility free from pest infestation The RP stated that for the third time in a year R1’s apartment at the facility is infested with bed bugs. LPA interviewed S1 who confirmed that the apartment in question had in fact been infested with bed bugs numerous times over the past year and that treatments from the pest control company work for a time, but the bed bugs return. R1 also confirmed that the bed bugs continue to be an issue. Allegation: Staff threatened the residents with eviction RP reported that residents at the facility were forced to sign an admission agreement addendum stating that all treatments for bed bugs would be paid for by the residents and that if the residents did not sign the addendum their lease would be terminated. S1 confirmed that the bed bug addendum to the admissions agreement started getting rolled out in 2020 and is now part of the facility’s standard admissions agreement. S1 further stated that residents were required to sign the addendum or face eviction. R1 stated that she signed the bed bug addendum because she was getting too stressed out by facing possible eviction. An email sent to the RP from S1 stated, "…the addendum we are asking to have signed has been a part of our leases since 2020. We are requiring all resident (sic) to sign it. It is a condition of R1 staying in the community .” Based on LPA observations and 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 this report and appeal rights provided.

On 10/11/21 starting at 3:25 pm Licensing Program Analysts (LPAs) L. Francisco and G. Clark conducted a health and safety check as a result of department receiving a priority 1 complaint. LPAs toured facility including but not limited to the apartments, bathrooms, common areas, kitchen, and outdoor area. Hot water temperature was measured at 117, 123 and 96 degrees F in 3 bathrooms. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Facility orders food supplies on a weekly basis. Resident's medications were kept locked in the med room. Smoke detectors are interconnected with the sprinkler system. Carbon monoxide detector observe. First-aid kit was complete. Fire extinguisher was observed to be full and last serviced on 5/20/21. There are no accessible bodies of water observed. The following deficiencies were observed: at 3:35 pm the hot water temperature was maintained at 123 degrees F. at 3:50 pm the hot water temperature in common bathroom was maintained at 96 degrees F. at 3:55 pm LPAs observed a dresser blocking the exit door in the memory care building The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 Failure to correct deficiencies by POC date may result in additional Civil Penalties. . Exit interview conducted Resident Care Director, Joann Nisperos . Appeal Rights and a copy of this report provided.

On 06/02/20201 Licensing Program Analysts (LPAs) Allison O'Hollaren and Lizette Francisco arrived unannounced to deliver amended reports dated 03/24/2021. LPAs met with Resident Care Coordinator, Ebony Foy. Exit interview conducted and a copy of this report was provided.

On 8/06/25 at 2:30 p.m., Licensing Program Analyst (LPAs) Greg Clark and Luisa Fontanilla arrived unannounced to conduct a case management visit on this date to request documents. LPAs meet with Anthony Garcia, Administrator (ADM) and explained the purpose of the visit. LPAs requested that ADM send LPA documents from the past 6 months from the pest control company that indicate the scope of work, what treatment is being done, where it is being done by 8/07/25. No deficiencies cited. Exit interview conducted conducted and a copy of the report provided.

On 7/24/25 at 2:50 PM Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct a case management visit. LPA met with Anthony Garcia, Administrator(ADM) and explained the purpose of the visit. LPA requested that ADM send LPA all invoices related bug bed treatment for the year 2025 by 7/30/25. Exit interview conducted, a copy of this report provided

***continues from LIC9099*** LPA's toured R1's apartment and observed that the sliding glass door is very difficult to operate. LPA's did not observe any rodents. This agency has investigated the complaint alleging staff do not keep the facility free of rodents . We have found that the complaint was 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 . Exit interview conducted, a copy of this report provided.

LPA interviewed S1 who stated that there has been an issue with R1 smoking in his room that he and the corporate management of the facility have been dealing with the issue for several months. S1 also stated that R1 is currently on a smoking cessation program. R1 has nicotine gum and is on a nicotine patch. The facility has also issued R1 a later dated 5/14/25 that references that section of the admission agreement that R1 is in violation of and that if there is another incident of him smoking in his room he will be evicted. LPA reviewed the letter during the visit. LPA interviewed R1 in his room at the facility. LPA did not observe any cigarettes, ash trays or any other items that would indicate R1 was smoking in his room. R1 stated that he knows he must follow the rules or face eviction. R1 also stated that he like living at the facility and does not want to get “kicked out.” This agency has investigated the complaint alleging staff are allowing residents to smoke in the facility. We have found that the complaint was 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 . Exit interview conducted, a copy of this report provided.

On 6/25/25, Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director, Anthony Garcia and explained the purpose of the visit. LPA toured the facility including but not limited to 3 residents’ apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 70 degrees F. The hot water temperature in a hallway bathroom was measured at 111.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic 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 4/25/25. Emergency Disaster Plan was last signed on 7/29/24. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 6/24/25. LPA reviewed 5 residents records and 5 staff records, and all were complete. LPA also reviewed a sample of resident’s medications. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

Continued from LIC9099. hadn't been any additional communication with any one at the facility regarding R1's financial change. S1 stated during initial interview the facility is a private pay facility only and do not accept SSI recipients. The rates for residents are set by corporate. During S1 interview on May 1, 2025, S1 stated he had heard that R1 was receiving SSI, and inquired with R1's guardian. LPA obtained email communication between S1 and R1's guardian dated February 4, 2025, regarding resources for R1, March 17, 2025, April 7, 2025, and April 17, 2025. S1 also stated there have not been any additional notices sent for the eviction process. S1 stated he has left messages with R1's family member, guardian, and ombudsman to meet and develop a plan to guide R1. On March 17, 2025, S1 inquired with the Oakland Regional Office regarding Provider Information Notice Summary 24-13 (PIN) and was given the incorrect information. No deficiencies issued during the visit. Exit interview conducted and a copy of this report was provided.

**REPORT CONTINUES FROM LIC 9099** LPAs interviewed S2 who stated that she was the primary staff person assigned to investigate the missing walker S2 stated that she found a walker in the library that she believed belong to R1. When S2 went to R1’s apartment to return the walker, she found an identical walker folded up behind R1’s door. S2 suspected that R1 took the wrong walker when she was leaving the library. Upon further inspection, S2 discovered there were total of four walkers in R1’s apartment. S2 also stated that R1 frequently leaves the walker behind. LPAs interviewed R1 in her apartment in the independent living building. R1 told LPAs that she has lived at the facility for over 20 years, and she is very happy with the care that she receives stating “I love it here, they are all so kind”. When LPAs asked R1 specifically about any issues with the walker, R1 stated that she had none and did not recall ever misplacing it. This agency has investigated the complaint alleging staff stealing resident's valuables . We have found that the complaint was 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. Exit interview conducted, a copy of this report provided.

Allegation: Facility did not provide comfortable temperature S1 stated that from time to time the thermostats in the Memory Care Unit need maintenance to operate properly. Upon notice of an issue S1 calls a HVAC company and they come out with-in a day or two to address the issue. LPA toured the memory care unit and found that the temperature in the unit was at a proper level and the residents all looked comfortable. Allegation: Facility staff is retaliating against the resident LPA found that there is no evidence to support this allegation. LPA observed R1 to be comfortable in the Memory Care Unit dressed in sweats and a black hoodie. LPA also could not find any evidence of any complaints filed regarding R1. This agency has investigated the complaint alleging: Unlawful eviction , facility did not provide comfortable temperature and facility staff is retaliating against the resident . We have found that the complaints were unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview conducted, a copy of this report provided.

**REPORT CONTINUES FROM LIC 9099** LPAs reviewed the letter dated 11/08/2024 that serves as a reminder to smoke off site. S1 stated that every residents received the letter on their doors. LPAs interviewed S2 who stated that she suspects a resident on the first floor of the independent living building is lighting his cigarette as he is living the building which is a violation of the rule as he is not off site. LPAs interviewed S3 who stated that she has never seen anybody smoking in the independent living building and she has never smelled smoke. LPAs also interviewed R1 who stated that she has seen a resident who uses a scooter lighting up his cigarette as he finds his way off of the site. R1 further stated that she has never seen anybody smoking in the building. This agency has investigated the complaint alleging staff did not keep the facility free from cigarette odor". We have found that the complaint was 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. Exit interview conducted, a copy of this report provided

*** report continues from LIC9099*** S1 stated that the facility has a contract for routine pest management with Orkin who come out to the facility weekly. The facility also has maintenance staff on duty to treat issues as they arise on a daily basis. As soon as S1 is made aware of bed bugs in R1’s apartment he calls Orkin to come out to access and treat the apartment. The apartment was checked on 7/2/25 by Orkin and is clear of bed bugs. This agency has investigated the complaint alleging staff did not keep the facility free from pest. We have found that the complaint was unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED .

On 02/09/26 at 12:40PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced Case Management visit to review the facility’s inclusion of a Bed Bug (Appendix N) Addendum on current and future residents’ admissions agreements dated 11/2024 and January 2025 as stated in the notification sent by ED dated 12/05/25 to all residents of the facility. This Addendum requires each resident to agree to the Lease and Bed Bug Addendum (Appendix N) terms and conditions or face potential eviction or termination of their lease agreement. LPA met with executive director (ED) and explained the purpose of the visit. At 12:55PM, LPA obtained a signed copy of resident's current admission agreement with Bed Bug Addendum (Appendix N) included. ED stated the new version of the residency admission agreement was approved by Licensing on 11/07/24 when there was a change in ownership and new management at the facility effective 01/10/2025 under Oakland Heights Senior Living. LPA advised ED the Department will review current residency admission agreement with Bed Bug Appendix N Addendum and follow-up with another case management visit. No deficiency cited during visit. Exit interview conducted and a copy of this report provided.

On 11/08/24 at 12:45 PM, Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct a case management visit. LPA met with Administrator, Anthony Garcia and explained the purpose of the visit. During the course of the Investigation of complaint #15-AS-20240228122658 dated 2/28/24 LPA had the opportunity to review an addendum to the admissions agreement for the facility titled "bed bug addendum." LPA found that the addendum is not in compliance with regulation. 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.

On 5/1/2025, at 3:30pm, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a Case Management visit. LPA met with Anthony Garcia, Executive Director and explained the reason for the visit. While LPA L. Hall was conducting a complaint investigation 15-AS-20250318163614 information was ascertained that on March 17, 2025, S1 inquired with the Oakland Regional Office regarding Provider Information Notice Summary 24-13 (PIN) and was given the incorrect information. LPA reviewed regulation 87464, specifically section (e), with S1, to provide information regarding residents that receive SSI after being admitted to the facility. No deficiencies issued during the visit. Exit interview conducted and a copy of this report was provided.

Continues from LIC 9099 S1 stated that the facility received the initial payment for the care, but no further payments were made. S1 started the eviction process on 03/01/2024. Eviction letter was sent to the person legally responsible via registered mail and a copy provided to the resident.LPAs reviewed the letter and found it to be compliant with the regulation. This agency has investigated the complaint alleging staff unlawfully evicted a resident. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted, a copy of this report provided.

Review of R1’s file revealed that R1 has a diagnosis of schizophrenia. Review of R1’s medication administration record reveled that R1 is compliant with taking his medication on a daily basis. On 4/20/24 R1 called 911 on himself and was transported to Kaiser Hospital. R1 was subsequently moved to St. Helena Hospital for further evaluation of his mental health condition where he remains as of today. There is no discharge date at this point. Interview with W1 revealed that he is happy with the care R1 receives at the facility and is hopeful that he can return to the assisted living side of the facility. W1 stating that R1 can be difficult, at times, to deal with and he feels facility staff do a good job dealing with R1. W1 also stated that facility staff keep him information of any issues regarding R1’s care or medical condition. Interviews with S1, S2 and S3 revealed that R1 is sometimes non-compliant but staff can usually gain his compliance. Interviews also revealed that R1 would refuse housekeeping services for months at a time and also refuse to see his doctors. All three staff stated that although R1 had his issues, they feel they can work with him to keep him safe and healthy. This agency has investigated the complaint alleging neglect of physical care. We have found that the complaint was 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 . Exit interview conducted, a copy of this report provided.

On 9/08/23 R1’s POA was changed via court order to a public guardian. The public guardian is currently working with the facility to arrange payment of back rent and the “Notice to Quit” is on hold. This agency has investigated the complaint alleging illegal eviction. We have found that the complaint was 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 . Exit interview conducted, a copy of this report provided.

On 7/02/23 R1 was observed to be below baseline behavior and was noted to have not eaten anything for 2 days. Facility staff called 911 and R1 was taken to San Leandro Hospital where he remained until returning to the facility on 7/08/23. Allegation: Resident sustained unexplained bruises from suspected abuse. Interviews with memory care staff revealed that while giving R1 his “bed baths” none of the staff observed any bruises, marks, or burns on R1. Staff also stated that R1 did not show any signs of pain from any type of fracture. Allegation: Facility staff neglected resulting in resident being severely dehydrated . Based on interviews and records R1 became depressed when W1 told him that he would be going out of town. Memory care staff attempted to feed R1 for 2 days (6/30 and 7/01/23) but he refused. On 7/02/23 R1 appeared weak and lethargic and refused to get up out of bed. 911 was called and R1 was sent out to the hospital. R1 was discharged back to the facility on 7/08/23. Allegation: Lack of supervision resulting in resident sustaining multiple fractures. At the time of admission R1 refused to let Pacifica staff perform a body check. Several small scratches were noted on R1’s elbow. W1 stated that he thought R1 was abused at his previous facility but didn’t provide any further details. While R1 was hospitalized (July 2-8, 2023) an x-ray was done. The x-ray revealed several fractures: a recent to semi-recent fracture on the right side of R1’s pelvis. This could have been caused by an incident at the facility where R1 slid down out of his wheelchair and ended up on the floor in a seated position. No hospital visit was made on that date, so the injuries are unknown. The x-ray also revealed that there was an old fracture to R1’s left collarbone and an older fracture to his lower back (T12 vertebra). The fractures were noted as “age indeterminate” meaning it was unclear how old these fractures were. ***report continues 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 ***report continues from LIC9099C*** Allegation: Staff did not observe change of condition in resident Staff notes from R1’s file indicate that staff were documenting R1’s declining condition in late June and early July 2023. Staff also attempted to reach W1 to inform him but staff reported that W1 was difficult, at times, to get in touch with. The Department has investigated the complaint alleging resident sustained unexplained bruises from suspected abuse, facility staff neglected resulting in resident being severely dehydrated, lack of supervision resulting in resident sustaining multiple fractures and staff did not observe change of condition in resident. We have found that the complaint was unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview conducted, a copy of this report provided.

LPA interviewed S1 who stated that the facility has a maintenance staff person on duty available to spray rooms upon request. There is also a monthly service contract with a pest control company also available to treat residents’ apartments for pests. The reporting party was not able to provide LPA with information if R1 ever requested treatment for pests. This agency has investigated the complaints alleging f acility elevator is in and staff did not keep facility free from pests. We have found that the complaints were unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED . Exit interview conducted, a copy of this report provided.

LPA observed the lunch service with about 50 residents having lunch, 4 servers and 1 care staff. There were no incidents during the observation. LPA interviewed 4 residents. Three of residents (R1, R2 and R3) interviewed reported that they have never seen or heard any altercations in the dining room. All 4 residents eat lunch in the Assisted Living dining room on a daily basis. R4 reported that he has on occasion heard voiced raised and some arguments happening. He has never seen anything escalate to a physical altercation. This agency has investigated the complaint alleging lack of supervision resulting in resident-on-resident altercations. We have found that the complaint was 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 . Exit interview conducted, a copy of this report provided.

On August 21, 2023, R1 reported to facility staff that she felt that she had new bites on her arms. Facility nurse applied hydrocortisone to the bites and informed the ADM. ADM emailed the family of the occupants of the Unit to inform them that he would be formulating a plan. ADM then called Orkin to return and inspect the Unit. Orkin returned on August 25, 2023, and treated the Unit with a chemical dusting. Upon closer inspection Orkin discovered there were felt banners on the wall of the Unit that had been removed during the heat treatment with bed bug residue on them. On August 29,2023, Orkin the ADM met with the family of the occupants of the Unit. The Unit will be deep cleaned and then heat-treated next week. LPA toured Unit 115 and observed Orkin technicians cleaning the Unit. This agency has investigated the complaint alleging staff does not prevent residents room from bed bugs we have found that the complaint was 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. Exit interview conducted, a copy of this report provided.

Page 2 During inspection, LPA turned on the faucets and flushed the toilets in residents rooms in Assisted Living and Memory Care Units, and didn't observe any clogging and water in the sink was observed draining properly. Executive Director stated that no pipe broke or have issue where water backed-up. If residents flushed paper towel in the toilet, the toilet clogged and they fix the problem right away. One out of six (6) staff interviewed stated that residents may at times use the sink in the toilet to clean cups, and food scraps may cause draining problem but they take care of the problem immediately. Four out of 5 residents interviewed stated didn't have clogging issue, and 1 was not able to provide information. Allegation: R esidents left in soiled diapers for an extended period of time. Four staff interviewed who had or still have direct contact and/or provided/providing care to the residents stated residents' diapers are changed at least 3x during shift. The other 2 staff indicated they have not observed any residents in soiled diapers. Five residents interviewed indicated either not using diaper, can toilet on their own or use diaper and being assisted or changed by staff. Allegation: Facility staff are not cleaning residents room. It was alleged that residents rooms were not cleaned, and their garbage not removed. Staff interviewed stated that rooms in Memory Care Unit are cleaned and trash taken out everyday while the the Assisted Living rooms are cleaned once a week. One out of 5 residents interviewed was not able to provide information on the cleaning of the room. LPA conducted inspection and although observed 2 rooms in Assisted Living unit with residents' belongings on the floor, the flooring was observed clean. ....continued on 9099C (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 Page 3 Based on information gathered, the allegations of facility in disrepair, residents left in soiled diapers for an extended period of time, and facility staff are not cleaning residents room are closed as unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiency cited. Exit interview conducted, and copy of this report provided.

Staff did not ensure that resident's original residence has been fixed since it was flooded over 6 months ago. R1 lived in SW102. R1’s kitchen was flooded in 10/2022. Roto Rooter was called but issue wasn’t resolved, and the kitchen keep flooding. R1 was moved to a larger apartment (SW117) down the hall from her former residence. During December 2022 and January 2023, the facility was trying to get Roto Rooter to take responsibility for the damage they did to the plumbing in the kitchen of SW102. During February and March 2023, the facility was getting bids for the needed repairs which were extensive. In April 2023 the plumbing under the kitchen floor was repaired. During May 2023 the facility again was getting bids to re-model the kitchen. A contractor was chosen in July 2023 and the scope of work is being finalized. Re-model work has started and currently a new floor is being installed. LPA interviewed R1 at the facility. R1 stated that there are a few things she doesn’t like about her current apartment but that she is “making do.” R1 is happy that she can go back to her old apartment several times a week to take care of her plants. R1 further stated that she is confident that the facility staff are working hard to get her back into her apartment. Staff did not ensure that facility front gate is operational. R&S Overhead Garage Door Company repaired the front gate on 7/20/23. LPA observed the gate to be operational during today’s visit. This agency has investigated the complaints alleging staff did not ensure that facility garage gate is operational, staff did not ensure that resident's original residence has been fixed since it was flooded over 6 months ago, and staff did not ensure that facility main gate is operational. We have found that the allegations are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED . Exit interview conducted, a copy of this report provided.

Staff failed to change residents’ diapers in a timely manner. RSD stated that residents in memory care that are incontinent are checked every 2 -3 hours and changed as needed. This is not documented as it is part of the daily schedule for care givers. Staff not repositioning resident R2 is wheelchair bound and spends most of her day in her wheelchair. When R2 needs to be changed R2 is taken by staff to her bedroom and placed in her bed to be changed. RSD stated there is no record of R2 having any pressure sores. Resident had unexplained weight loss. R2 weighed 134.8 lbs. on 3/3/22 and 127 lbs. on 3/01/23 for a weight loss of 7.8 lbs. which is 5.7 percent. This is with-in the normal range of a person in their late 80’s. R2 also takes Ensure daily to help with weight maintenance. Facility elevator is inoperable. ADM reported that the memory care elevator was out of service for a period of 6 – 8 weeks while the elevator was getting an upgrade. The elevator was back in service on 4/04/23. Resident fell resulting in a bruise. RSD reported that R2 bruises easily due to the medications she takes. R2 is a fall risk but hasn’t had a fall in over 1 year. This agency has investigated the complaints alleging staff failed to change residents’ diapers in a timely manner, staff not repositioning resident, resident had unexplained weight loss, facility elevator is inoperable, and resident fell resulting in a bruise. We have found that the allegations are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED . Exit interview conducted, a copy of this report provided.

On 7/13/23 at 3:10 p.m., Licensing Program Analyst (LPA) Greg Clark conducted a Health & Safety inspection as a result of a priority 1 complaint. LPA met with Administrator, Anthony Garcia and explained the purpose of the visit. LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, and outdoor area. Hot water temperature was measured at 118.5 degrees F in the hallway bathroom. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Refrigerator temperature was observed at 38 degrees F. Resident's medications were kept locked in the med room. Smoke detectors are interconnected with the sprinkler system. Carbon monoxide detector observed. First-aid kit was complete. Fire extinguisher was observed to be full and last serviced on 5/26/23. There are no accessible bodies of water observed. Indoor and outdoor passageways are free of obstruction. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

On 8/10/23 at 1:00 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to complete annual inspection. LPA met with Administrator, Anthony Garcia and explained the purpose of the visit. LPA toured the facility including but not limited to 4 residents’ apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 70 degrees F. The hot water temperature in a sample of residents’ shared bathroom were measured at 110.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. LPA interviewed 5 residents and 5 staff. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

ADM stated that as soon as he was made of the situation (7/24/23) he and the facility maintenance director called Bay Area Bed Bugs, Orkin and several other companies. Orkin inspected the unit on 7/25/23 and responded with a proposal. ADM agreed to the proposal and the service was scheduled for 7/31/23. LPA received a copy of the Orkin invoice dated 7/31/23. LPA interviewed R1 who stated that she is no longer being bitten. R1 sated “they killed them all.” LPA toured Unit 115 and observed no evidence of bed bugs. This agency has investigated the complaint alleging facility has pests we have found that the complaint was 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 . Exit interview conducted, a copy of this report provided.

Page 2 On this day, 2/24/23, Anthony Garcia stated that they are in the process of hiring Memory Care Services Coordinator. Based upon interviews, ,the Department has found the allegation as substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Allegation: Facility has pests. It was alleged that rats are being found in the dining room and kitchen, and have chewed through the boxes of emergency food supply stored in the basement. On 12/01/21, LPA conducted inspection, and observed mouse droppings in the food storage, and canned food with small bites on the labels LPA interviewed staff S1 on that same day who stated that food supplies has to be moved from large to small storage due to rat infestation. Based upon interview and inspection, the Department has found the allegation is substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Allegation: Facility is not conducting fire drills as required. It was alleged that the facility has not conducted a fire drill in over 6 months. On this day. 2/24/23, LPA obtained copies and reviewed fire drill records in facility's file which showed dated 9/22/22, 10/27/22 and 1/27/23. LPA also interviewed Resident Services Director Joanne Nisperos who stated they only started doing fire drills when Anthony Garcia became the Executive Director. Based upon interview and record review, the Department has found the allegation as substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. ...continued on 9099C (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 Page 3 Allegation: Facility is unsanitary It was alleged that trash is overflowing in all of the buildings, in the stairwells and the trash chutes. On 12/01/21, LPA conducted inspection, and observed on the lowest level on the stairwell in Memory Care unit a shopping bag with soiled diapers. used disposable gloves and soiled pads. Based upon inspection, the Department has found the allegation as substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited from Title 22 California Code of Regulations and listed on 9099Ds. Failure to submit proof of corrections by plan of correction due dates, and any repeat violation within 12 month period may result in civil penalty. Deficiencies and plan and proof of corrections were discussed with Anthony Garcia. Exit interview conducted. Copy of this report, Appeal Rights and LIC9098 Proof of Correction form 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 On 12/01/21, LPA interviewed Ruth Ocon, the Executive Director at that time who stated that front door lobby was not locking about 6 months ago from the day of interview. It was fixed and worked for about a month and got broken again. On that same day and on this day, 2/24/23. LPA tested the door by pushing the bar for the disabled to push to open the door, and observed was working properly. On 12/01/21, staff was interviewed who stated that it's been working and that she was told that the door is locked at night. On 2/24/23, Anthony Garcia was interviewed who stated that the door has an alarm that is automatically activated at certain hour at night. Copy of record obtained showed that the sprinkler system, kitchen hood system, and exhaust were serviced on 10/17/22. LPA inspected the kitchen vents and hood on 2/24/23 which were observed clean. Based on interviews, records review and inspection conducted, the Department has investigated the above allegation and found as unsubstantiated. A finding that the complaint allegation 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 violations occurred. Allegation: Staff allow resident to smoke inside the facility. It was alleged that there's a resident (R1) in AL unit that constantly smoke inside her room. On 12/01/21, LPA interviewed R1 who stated she smoked inside her room, but when the staff discovered, she quit smoking. Allegation: Staff are not properly trained. It was alleged that staff do not have the required training such as dementia training and mandated reporter training. On 2/24/23, LPA asked for staff records and copies of staff training, ED provided copies of training that were download from the computer, however, records do not show the number of required training. Based on records review conducted, the Department has investigated the above allegation and found as unsubstantiated. A finding that the complaint allegation 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 violations occurred. No citation issued. Exit interview conducted and copy of this report provided.

On 10/24/24 at 1:15 pm, Licensing Program Analyst (LPA) Greg Clark conducted a case management visit pertaining to a letter received by the Oakland CCL ASC Regional Office from the facility. LPA met with Executive Director(ED), Anthony Garcia and explained the purpose of the visit. On July 9, 2024, the Oakland CCL ASC Regional Office received from the facility a letter of intent to de-license the third floor of the physical plant and convert those units for Independent Individuals who are 55 years of age and older. The letter did not specifically request approval from CCL and had insufficient detail pertaining to how the co-mingling of Independent aged 55+ renters, and licensed RCFE Assisted Living residents, would be managed to ensure the Health & Safety of the Assisted Living residents. LPA interviewed the ED who stated that the facility currently has seven(7) 55+ independent living residents at this time. On 10/16/24 LPM Jeremy Fong and on 10/24/24 LPA Greg Clark and ED confirmed that the facility’s website is advertising for independent renters aged 55 and older, which constitutes a change to the Plan of Operation without having obtained approval from Community Care Licensing. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.

Based on records review and interviews, the allegation is substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency is cited from Title 22 California Code of Regulations and listed on 9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violation within 12 month period may result in civil penalty. Deficiency and plan and proof of correction were discussed with Anthony Garcia. Exit interview conducted. Copy of this report, Appeal Rights and LIC9098 Proof of Correction form 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 Page 2 Allegation: Staff left resident on the floor for expended period of time. It was alleged that R1 fell off from bed, and was left on the floor for extended period of time. Family member (FM1) was interviewed on 3/25/21 who stated they saw on the camera they placed on R1’s room that R1 was on the floor on 3/13/21 and 3/14/21, and R1 was left unattended for 2 to 3 hours. LPA tried to obtained video footage from FM1 but was unsuccessful. LPA was not able to obtain information from R1 of what had happened on the alleged incident dates. Another family member (FM2) was interviewed on 12/01/21 who stated there were some issues but indicated caregivers are good in providing good care to the resident. Based upon interviews conducted, and FM1 unable to provide video footage of the alleged incident, the Department has investigated the above allegation and found as unsubstantiated. A finding that the complaint allegation 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. Allegation: Staff do not follow the admission agreement in accordance with the service plan. It was alleged that per Admission Agreement R1 is to be checked every hour. FM1 was interviewed on 3/25/21 who stated that R1 is on an hourly check per Admission Agreement. They were verbally told R1 is on level 5 care needs; however, they do not know what is level 5. Copies of Admission Agreement and Needs and Services Plan were obtained and reviewed by LPA. Although Admission Agreement showed R1 is on level 5 based on the rate fee charge, this document and the Needs and Services Plan didn’t indicate R1 is on hourly check. Review of Appendix B-1 of Admission Agreement showed the rate charge for R1 falls under level 5. On 2/24/23. Resident Services Director was interviewed who stated that the status checks for level 5 resident is every two hours or 4 times per 8 hours shift. Based upon interviews conducted, and records review, the Department has investigated the above allegation and found as unsubstantiated. A finding that the complaint allegation 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. ,,,,continued next on 9099C (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 Page 3 Allegation: Resident's room does not have adequate heater. It was alleged that the heater in R1’s room does not work, and staff brought in a temporary heater which is not adequate. FM1 was interviewed on 3/25/21 who stated that R1 told FM1 that wall heater on R1’s room was not working on 3/14/21 and the staff only brought in the floor heater that day and it was not working either. LPA verified and FM1 said the wall heater was still not working but the floor heater was already working, On 3/26/21 and 12/01/21, LPA conducted inspection. LPA observed on 3/26/21 that R1’s room was vacated as R1 moved to Memory Care Unit on the night of 3/25/21. LPA observed the heater working. LPA was not able to obtain information from R1. On 3/26/21, LPA interviewed Ruth Ocon, the Executive Director during that time who stated she never received any complaint about heater not working. On 12/01/21, LPA interviewed R2 who at that time was on the room vacated by R1 stated the temperature in the room is okay and the heater is working. R3 stated the heater in R3's room is working, Based upon interviews and inspection conducted, the Department has investigated the above allegation and found as unsubstantiated. A finding that the complaint allegation 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. Allegation: Staff denied resident the right to reasonable visitations. It was alleged that staff denied the family member visits to R1 under any condition, even though everyone in the facility is already vaccinated for Covid-19. On 3/25/21, LPA interviewed FM1 who stated that they were allowed to get inside R1's room when they were moving-in R1's furniture on 3/12/21. They were told the facility has 2 positive cases, and that they cannot visit. However, when R1's other family members went to the facility on 3/14/21, they were allowed to get in. FM1 stated there's a lot of confusion in regards to visitation, and that were not told about window and/or virtual visitations. They were only allowed to visit Tuesday, 3/16/21. LPA reviewed facility history of Covid-19 positive cases which showed a case was reported on 3/09/21, 2 days before R1 moved-in. LPA interviewed Ruth Ocon on 3/26/21 who stated when the facility has Covid case, they are not allowing visitation until Public Health clears the facility. However, when there's new admission, they are allowing the family to come inside on the day of move-in, so they can set-up the room, and move-in some stuff the resident will need. ....continued pon 9099C (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 Page 4 The facility's side door is open, and the family members' temperatures are check Ocon also stated that R1’s niece (name she does not remember) came to visit but they asked her to leave, and explained about the facility not allowing indoor visitation. Copy of email blast dated 3/08/21 showed Ocon provided information to staff which includes visitation will be outside only. Ocon also stated an email blast was sent to residents' family members. On 12/01/21, LPA interviewed another family member (FM2) and resident R2. FM2 stated when she visits, she test for Covid. FM2 also stated she does not have any problem with visitation. R2 stated R2’s family members come and visit, and were allowed to come in. R2 also stated that staff checks the family members’ temperatures first before they are let in. LPA conducted inspection on 12/01/21, and observed a tent in the facility courtyard for outdoor visitation. Based upon interviews and inspection conducted, the Department has investigated the above allegation and found as unsubstantiated. A finding that the complaint allegation 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 violations occurred. No deficiency cited. Exit interview conducted. and copy of this report provided.

**report continues from LIC9099*** S1 stated that she has not seen any rodents in the kitchen. S1 also stated that she is in the process of developing a cleaning schedule for the kitchen . Currently staff clean as they work. S2 and S3 also stated that thetyhave not seen any rodents in the kitchen. S3 demonstrated to LPA how the floor drains in the kitchen are cleaned. All drains were observed to be clean at the time of the inspection. This agency has investigated the above allegations. Based on records reviewed, and interviews conducted, the above allegations are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview conducted and a copy of this report provided.

Questionable Death. On 6/27/22 W1 decided to move R2 back to her home so she could monitor his care more closely. While moving R2 from his bed to a wheelchair he collapsed. The hospice nurse told S1 to call 911. S1 did so and then left R2’s room to retrieve his POLST from her office. When S1 returned to R2’s room the paramedics had pronounced R2 deceased. Facility administered medications to resident without physicians order. Facility mismanaged medication resulting in overmedicating resident in care. S1 stated that all medications for R2 were handled by either W1 or the hospice nurse. LPA reviewed R2 medication orders on file and MARs from 5/31/2022-6/27/2022. No medications were administered by facility staff. All medications listed on the MARs were initialed by staff as “given to family to give later” and matched physician orders on file. W1 could not recall which medications were administered without the proper order nor which date said medications were taken by R2. Personal rights- resident spoken to inappropriate manner. Personal rights- facility staff handled resident in a rough manner. Both S1 and S2 stated that they never saw any staff members at the facility speak to R2 in an inappropriate manner or handle R2 roughly. Responsible party not notified about resident's change in condition. Both S1 and S2 stated that they were in constant contact W1 regarding her father’s condition. Both S1 and S2 showed LPA numerous text messages on their phones to and from W1. Staff unable to communicate with residents due to language barrier. S2 stated that some of the housekeeping staff speak very little English but that they are not responsible for resident care. Care staff all speak English. ***Report continues 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 ***Report continues from LIC9099C*** Lack of supervision- resident sustained several unwitnessed falls with injury. LPA reviewed R2’s SIR’s and there was no documentation of any falls. S1 stated she never was told by staff that R2 had fallen. This agency has investigated the above allegations. Based on records reviewed, and interview conducted, the above allegations are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview conducted and a copy of this report provided.