Piedmont Gardens #1

On 3/1/2022 starting at 1:00 p.m., Licensing Program Analyst (LPA) Catherine Lin arrived unannounced to conduct Infection Control Inspection. LPA met with the Wellness and Assisted Living Director Zinnia Koch and disclosed the purpose of the visit. Upon entry, LPA’s temperature was checked and Covid-19 questionnaire was asked through a Cubigo. LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, bathrooms, kitchens, common areas, and outdoor areas. There is one central entry point for universal screening for staff, residents, and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a sufficient 2-day perishable and one-week non-perishable food supply. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has 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 Wellness and Assisted Living Director, and a copy of this report provided.

, On 02/04/2024 at 01:30 AM, Licensing Program Analysts (LPA) David Doidge arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Director of Wellness and Assisted Living Zinnia Koch and explained the purpose of the visit. LPA toured the facility including but not limited to, bedrooms, bathrooms, multiple activity rooms, kitchen, and common area. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 72 degrees Fahrenheit. The hot water temperature in a common bathroom was measured at 112.7 degrees Fahrenheit. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, and sharps are locked and inaccessible to residents in care. Fire extinguishers were last serviced on 09/15/2025. Emergency disaster drills and fire are drills conducted quarterly; last conducted on 01/08/2026. 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

On 06/16/2024 at 01:20 PM, Licensing Program Analysts (LPAs) David Doidge and Andrew Christy conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 06/15/2025. LPAs met with Zinnia Koch, Director of Wellness and Assisted Living (DWAL) and explained the purpose of the visit. Facility submitted a UIR to CCLD for a resident that reported staff were rough while assisting with using bedside commode. Resident's son reported incident to DWAL who then created the UIR. DWAL stated as resident was transitioning onto commode,resident accidentally sat on hand causing a skin tear on left thumb. Skin tear was cleaned and band-aid applied. Resident could not remember the incident occurring when staff interviewed resident. LPAs interviewed resident. Resident could not recall how the skin tear was caused, but thought it was from staff. Skin tear is about a centimeter long not deep on inside of thumb. LPAs got resident to remove old band-aid to look at it. Wound was then cleaned and re-bandaged. Staff involved has been placed on leave while DWAL investigates, as procedures. LPAs collected the Physician’s Report (602), Appraisal Needs and Services (ANS), and face sheet for resident listed on the Unusual Incident Report (UIR). No deficiencies issued during the visit. Exit interview conducted and a copy of this report was provided.

On 05/20/2024 at 02:10 PM, Licensing Program Analyst (LPA) David Doidge conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 05/06/2025. LPA met with Zinnia Koch, Director of Wellness and Assisted Living and explained the purpose of the visit. LPA collected the Physician’s Report (602) for resident listed on the Unusual Incident Report (UIR) and interviewed two (2) staff in the matter. Facility submitted a UIR to CCLD for a resident that was administered the wrong medication. S1 reported that on 05/06/2025, one of the medtech called in sick leaving them short staffed. A licensed nurse usually handles the distribution of medications. To compensate, an assisted living nurse was asked to help out. This nurse is not familiar with the residents. Medication was selected according to the Electronic Medication Administration Record (EMAR) by a medtech. It was then given to the assisted living nurse to be administered. The assisted living nurse, unfamiliar with the residents, accidentally gave the medication to the wrong resident. R1 was monitored by staff. PCP and family were notified as well as poison control. R1 showed no signs of adverse reaction. S1 conducted a one-on-one with the assisted living nurse reminding the nurse to next time be more cautious and ask questions when unsure. Steps are being taken to prevent further occurrences. Staff had in-service training. No deficiencies issued during the visit. Exit interview conducted and a copy of this report was provided.

Continued from LIC9099. Allegation: Facility neglected to provide Resident adequate basic care needs. During initial interview with RP it was stated that when R1 returned for her follow-up appointment on 9/19/2023, it appeared that R1's daily activities of daily living (ADLs) were not being met. S1 stated during interview that R1 is accompanied to her appointments by her daughter. Interview and record review indicated that R1 is bathed twice a week. S1 stated that if the health nurse (that comes once a week) bathes R1 the facility does not document it. LPA reviewed the care plans and MARs during the investigation and observed that two (2) medications were prescribed to assist R1 with basic care needs. Therefore, the facility did not neglect to provide R1 adequate basic care. Allegation: Facility did not follow physician's orders. RP stated facility did not follow orders that were given upon R1 being discharged from procedure. LPA observed discharge summary and physician's order for R1 during record review. Review of clinical notes indicated that on 9/14/2023, staff tried to remove dressing from wound but was not able to due to dried blood. Notes also indicated that staff would have day shift contact doctor and continue to soak wound to loosen. Staff contacted nurse on 9/15/2023, and was told to give it 1-2 more days. Staff tried again on 9/16/2023, but R1 expressed pain. On 9/17/2023, staff requested nurse. Nurse arrived on 9/18/2023. On 9/19/2023, staff called clinic to have R1 seen for dressing to be removed. R1 was seen and returned with new discharge instructions, which LPA observed during record review. 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 violations occurred. Exit interview conducted and a copy of report was given .

Continued from LIC9099 S1 reported residents living in independent living are able to administer own medications. S1 also stated that residents in assisted living and memory care receive assistance in medication management through eMAR. Therefore this allegation is Unsubstantiated. Allegation: Staff did not provide proper supervision to resident in care resulting in an injury Investigation Findings: W1 reported to the department that resident fell in the room and needed to be sent to the hospital and received stitches on his head. R1 stated that R1 had a fall and that staff immediately responded and initiated care. Staff notified R1's responsible party as R1 declined to go to emergency room (ER). Responsible party was able to take R1 to ER. S1 reported that R1 is in independent living and therefore has different level of care, and staff only respond to R1’s calls, but do not constantly supervise R1. Therefore the allegation is unsubstantiated. Allegation: Staff did not ensure that the resident's hygiene care needs are properly met. Investigation Findings: W1 reported to the department that the staff are not washing the resident’s hair and are not cutting his nails. W1 also reports that R1’s apartment cleanliness has been neglected. LPAs interviewed R1 in R1’s apartment. LPAs found apartment to be clean and well kept and odor free. R1 reports housekeeping visits every two weeks and has not refused services. R1 appeared well groomed, and alert and oriented of R1's current living situation. Therefore the allegation is unsubstantiated. 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 are unsubstantiated. No deficiencies cited during vsit. Exit interview conducted and a copy of this report provided.

On 01/24/2024 at 09:30 AM, Licensing Program Analysts (LPA) D. Doidge arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director Daniel Wittman and explained the purpose of the visit. LPA toured the facility including but not limit to, bedrooms, bathrooms, multiple activity rooms, kitchen, and common area. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 72 degrees Fahrenheit. The hot water temperature in a common bathroom was measured at 115 degrees Fahrenheit. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, and sharps are locked and inaccessible to residents in care. Fire extinguishers were last serviced on 09/09/2024. Emergency disaster drills and fire are drills conducted quarterly; last conducted on 01/09/2025. 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

On 4/3/2024 at 11:30am, Licensing Program Analyst (LPA) L. Hall conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 2/16/2024. LPA met with Zinnia Koch, Director of Wellness and Assisted Living and explained the purpose of the visit. S1 submitted a self reported incident for staff misconduct that occurred on 2/14/2024. S1 stated S3 had informed S4 that he witnessed S2 rough handling R1. S2 was suspended pending investigation on 2/14/2024 and returned on 2/19/2024. The facility conducted an internal investigation and found there was no intent to harm R1 and the handling of R1 was misinterpreted. Further interviews from the internal investigation were conducted and there was no complaints. LPA conducted a record review of S3's files and did not observe any previous adverse actions taken. LPA tried to interview R1, but was unsuccessful due to her diagnosis. LPAs collected the following documents: resident roster, staff roster, and an follow-up incident report dated 2/19/2024 No deficiencies issued during the visit. Exit interview conducted and a copy of this report was provided.

On 3/22/2024 at 8:45 AM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Daniel Withman, Executive Director/ Zinnia Koch Director of Wellness and Assisted Living and explained the purpose of the visit. Administrator Certificate number: 6059871740 expire on 6/10/2025. Liability Insurance expire on 1/1/2025. LPA inspected the facility including but not limited to resident apartments, bathrooms, dining rooms, common living areas, kitchen, and outside areas. The room temperature and lighting were adequate for the safety and comfort of the residents. Rooms were furnished appropriately and observed to be clean and in good repair. All rooms have private bathrooms, and showers on the 8th and 9th floor which were equipped with grab bars and safety/nonskid floors/mats. There was an adequate supply of 2-day perishable and 7-day non-perishable foods. Refrigerator temperature is measured at 35 degrees Fahrenheit. Freezer temperature was measured at -5 degrees Fahrenheit. Kitchen and food preparation areas were observed to be clean and in compliance. There were no bodies of water or fire safety hazards observed. All indoor and outdoor passageways were kept free of obstruction. Facility is equipped with smoke detectors, sprinklers, and fire alarm. Memory Care Unit doors were equipped with wander guard. Fire extinguishers throughout facility were fully charged and last inspected on 3/1/2024. Last Fire/Earthquake Emergency drill was conducted on 3/14/2024. The facility's fire clearance is approved for 321 residents. Administrator is on site at least 40 hours a week to oversee the business operation. There is an adequate number of trained staff to meet residents' needs during inspection. Staff assisting with activities of daily living and medications had the necessary training. LPA observed hot water temperature measured in residents’ apartments measured between 110–118 degree Fahrenheit. LPA reviewed 6 residents records. LPA reviewed 8 staff records and 8 of 8 have current first aid training and associated to the facility. LPA reviewed a sample of resident’s medications. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

On 9/29/2023 at 1:45 PM, Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct a case management visit. LPA met with Yuri Flores, Director of Human Resources (DHR) and explained the purpose of the visit. LPA went to the facility to deliver an Immediate Exclusion letter. Immediate Exclusion letter was delivered to DHR. LPA has advised DHR to disassociate the individual from their facility. DHR stated that S1 is currently not a staff member at this facility. Census will be provided at a later date. Exit interview conducted and a copy of this report provided.

On this day at around 10 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct a case management visit related to an incident that occurred at the facility. LPA met with Memory Care Manager Laura Roberts and explained the purpose of visit. Director of Wellness Zinnia Koch arrived at the facility and met with LPA at a later time. . During the visit, LPA interviewed Koch , Roberts, licensed nurse and 8 residents. All residents interviewed state they feel safe living at the facility. And that the staff treat them well. LPA obtained records for Resident 1 (R1). Koch, Roberts and Nurse all confirmed with LPA that the agency caregiver has been removed from the facility since the incident. At around 11:25 am, LPA reviewed video footage with Koch and Roberts. LPA was unable to obtain video footage from the facility. The facility participates in the Safely You program. The incident will be cross reported to the Home Care Services Bureau (HCSB) for further investigation. A copy of this report was provided to Roberts.

Continued from LIC9099. medications. Notes from the RP, clinical notes, and the MAR from the facility indicated R1 refused medication on several occasions. Facility would sometimes contact R1's responsible party to persuade R1 to take medications. Clinical notes dated 3/4/2023 indicated comfort meds were received for R1. Further clinical notes dated 3/11/2023 indicated the facility had not received signed orders for medication; however, on 3/15/2023, the facility received the updated medication list, changes were noted, and profiled was updated. R1 no longer resides at facility. Based on the investigation the above allegations are unsubstantiated. Allegation: Resident’s bathroom fan is in disrepair. During interview RP stated there were multiple bathroom fans in disrepair for two (2) months. LPA did not observe a work order for a bathroom fan. LPA toured apartment where R1 resided and two (2) additional apartments and did not observe fans in any of the bathrooms. Allegation: Staff mishandling residents medication. RP stated during interview that R1 had found a pill on the floor. During interviews and records reviews LPA was not told or did not observe where medication was found by staff or any other person. LPA obtained medication management training records for the licensed nurses, CNAs and Med Techs dated 3/10/2023 to 3/14/2023. 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 violations occurred. Exit interview conducted and a copy of report was given .

On 2/22/23 at 3:00 p.m., Licensing Program Analyst (LPA) G. Clark arrived unannounced to deliver amended report for the allegation of unlawful eviction (see LIC9099 dated 2/16/23). LPA met with Jana Gesinger, Health Services Administrator and explained the purpose of the visit. Amended report delivered to administrator. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

On 11/23/22 at 11:15AM, Licensing Program Analyst (LPA) C. Lin conducted an unannounced case management visit as a result of receiving residents from Grand Lake Gardens (GLG) and check on residents. LPA met with Wellness Director and explained the purpose of the visit. During visit, LPA obtained staff schedules. A total of 37 residents from GLG are currently living in PG. During visit, LPA met with 4 residents. 1 resident brought up a concern of call button issue. the Wellness Director was able to show resident how to use it correctly. A Spiritual Care Coordinator has been arranged by HumanGood and is currently supporting residents as needed. Other than that, residents stated that they were safe and comfortable living in facility. Supplies were adequate and staffing is stable. There was no imminent health/safety concerns on today's date. Exit interview conducted with Wellness Director and copy of this report provided.

On 11/9/22 at 2:00PM, Licensing Program Analyst (LPA) C. Lin conducted an unannounced case management visit as a result of receiving residents from Grand Lake Gardens (GLG) and check on residents. LPA met with Wellness Director and explained the purpose of the visit. A total of 35 residents from GLG are currently living in PG. During visit, LPA met with 6 residents. 1 resident brought up a concern of resident's mental health after the fire incident, LPA discussed it with Wellness Director who stated that she would follow up. Other than that, residents stated that they were feeling safe, fed well, and their needs were met. Supplies were adequate and staffing is stable. There was no imminent health/safety concerns on today's date. Exit interview conducted with Wellness Director and copy of this report provided.

On 11/2/22 at 10:50AM, Licensing Program Analyst (LPA) C. Lin conducted an unannounced case management visit as a result of receiving residents from Grand Lake Gardens (GLG) and check on residents. LPA met with Wellness Director and explained the purpose of the visit. During visit, LPA obtained GLG resident's roster and Piedmont Gardens (PG) staff schedules. Total of 32 residents from GLG are currently living in PG. 1 resident moved out to facility Valle Verde in Santa Barbara where is close to family. LPA met with 6 residents who stated that they were feeling safe, fed well, and their needs were met. Adequate food, paper, PPE supplies were observed, staffing is stable. There was no imminent health/safety concerns on today's date. Exit interview conducted with Wellness Director and copy of this report provided.

On 10/28/22 at 9:20AM, Licensing Program Analysts (LPAs) C. Lin conducted an unannounced case management visit as a result of receiving residents from Grand Lake Gardens (GLG) and check on residents. LPA met with Wellness Director and explained the purpose of the visit. During visit, LPA obtained GLG resident's roster and Piedmont Gardens (PG) staff schedules. Total of 32 residents from GLG had moved in to PG including 3 of them admitted to PG prior to the fire. LPA interviewed 5 residents who stated that they were happy living at PG, they were fed well and needs were met. Some GLG staff were transferred to PG to work so staffing is stable. Adequate food, paper, PPE supplies were observed. There was no imminent health/safety concerns on today's date. Exit interview conducted with Wellness Director and copy of this report provided.

On 10/14/22 at 2:00PM, Licensing Program Analysts (LPAs) C. Lin and L. Francisco conducted an unannounced case management visit as a result of receiving residents from Grand Lake Gardens due to evacuation from major fire. LPAs met with Wellness Director and explained the purpose of the visit. During visit, LPAs obtained resident's roster from Piedmont Gardens (PG) and Grand Lake Gardens (GLG) with contact information, staff schedules, LPAs observed that 20 residents from GLG were admitted to (PG) from 10/14/22 to 10/16/22. Out of 20 residents, one resident was discharged from hospital and admitted to Skill Nursing on 10/16/22, one of them was admitted to Assisted Living on 10/14/22, and 18 of them were admitted to Independent Living on either 10/14/22 or 10/15/22. The Administrator from GLG, Scott Mueller arrived at PG at 2:30pm and provided updates to GLG residents. GLG resident roster indicated that 20 other residents stayed in Hyatt House in Emeryville, the rest of 43 residents stayed at home with family member. LPAs were advised that it would take at least 3 months to reopen GLG. Food, paper, PPE, and other supples are adequate. Staffing is stable. Exit interview conducted with Wellness Director and copy of this report provided.

On 10/14/22 at 2:00PM, Licensing Program Analyst (LPA) C. Lin conducted an unannounced case management visit as a result of receiving residents from Grand Lake Gardens due to evacuation from major fire. LPA met with Administrator and explained the purpose of the visit. LPA observed that Piedmont Gardens opened 2 dining halls to accommodate residents from Grand Lake Gardens. Residents were safe and chatting in the dining rooms. Staff were assisting residents for getting clothing, refiling medications, and contacting their families. Administrator stated that most of residents from Grand Lake Gardens would be placed in hotel(s) in Emeryville except a few of them who require medication assistance might stay in Piedmont Garden. Food, paper, PPE, and other supples are adequate. Staffing is stable. Exit interview conducted with Administrator and copy of this report provided.