Oakmont of Riverpark.

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management – Incident visit to the above facility. The LPA met with Executive Director Kailey Vanderwall and Erik Bleitz explained the reason for the visit. Entrance interview conducted. The reason for today's inspection is to follow up on a self-reported death report received on 03/11/2025. The report pertains to the death of Resident #1 (R1). It was reported R1 was sent to the hospital on February 23th due to a fall and passed away on March 8th at the hospital. Due to interviews conducted and record review, no deficiencies cited at this time regarding the death of R1. Exit interview conducted. A copy of the report was issued to the Executive Director.

Licensing Program Analyst, Zabel Chochian arrived on 05/28/2026 for an unannounced inspection to follow up on a substantiated allegation of a complaint investigation. The LPA met with Executive Director Kailey Vanderwall . On February 9, 2023, the Department concluded a complaint investigation regarding the following allegation: Facility staff failed to provide an appropriate level of supervision which resulted in resident falling and sustaining a fracture. The licensee was cited for California Code of Regulations (CCR) 87464(f)(1) Basic Services . At the time of the complaint visit on February 9, 2023, an immediate civil penalty of $500 was issued. Due to the fact that this was a repeated violation, an additional $500 was levied. The Licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49(f). The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code Section 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by the facility not providing adequate care and supervision for the resident (R1). R1 fell and sustained a fracture of the right humerus and bruise of the right eye, which required hospitalization. Today, 05/28/2026 , the Department will be issuing a civil penalty per Health and Safety Code § 1569.49(f) for a violation that the Department determines constitutes as serious bodily injury in the amount of $10,000. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 However, since an immediate civil penalty of $500 was previously issued on February 9, 2023, the amount of the civil penalty issued today will be $9,500. Exit interview conducted. A copy of the report issued. Appeal rights provided. Executive Director, Kailey Vanderwall and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.

(PAGE 2) Report continued from LIC 9099... On the allegations, Administrator is not at the facility for a sufficient amount of time and Administrator did not ensure the facility had a designated substitute in their absence it is the concern of the Reporting Party (RP) that the ED arrives between approximately 11:00 a.m.–12:00 p.m. and leaves between 3:00 p.m.–4:00 p.m. impacting timely decision-making regarding resident care while leaving no one in charge in their absence. To investigate this complaint, LPA conducted in person interviews, file and record review and obtained copies of pertinent documentation relevant to the investigation. Staff interviews revealed that the ED is on site daily, Monday – Friday with the start time typically ranging from 8:00 a.m. to 9:00 a.m., and usually not past 9:00 a.m. due to a standing 9:30 a.m. daily Director’s meeting. The exact time may fluctuate depending on community needs, events, or coverage of NOC-shift schedules. Administrative staff, including the ED, make themselves available to residents and staff. If one director is not available, another director is present to address concerns. The ED is regularly on site and remains available after hours. During NOC shift hours, depending on the urgency of the issue, the Health Services Director (HSD) is contacted and “responds promptly”. The ED may also be contacted by staff or any of the other directors. It was noted that “There is always a director available either in person, by phone, or by text”. When the ED is not on site, a designee is always assigned. Typically, the Business Office Director serves as the designee; however, since the Business Office Director is currently new to the role, the HSD has been serving in that capacity. Residents are notified weekly via email and a hard-copy notice placed in their mailbox, which includes ED updates, community updates, and information on the designated manager on duty for specific days. Record review revealed that the ED is scheduled Monday through Friday from 8:00 a.m. to 6:00 p.m. During today’s visit, LPA obtained copies of the facility designee forms listing the Health Services Director, Maintenance Director, Memory Care Director, and Business Office Director. Although the allegations may have happened or are valid, there is insufficient evidence to prove the alleged violations did or did not occur. Therefore, the allegations of Administrator is not at the facility for a sufficient amount of time and Administrator did not ensure the facility had a designated substitute in their absence are deemed unsubstantiated at this time. Exit interview conducted. Report was reviewed and a copy was provided.

Licensing Program Analyst (LPA) Erica Mosley arrived at the facility unannounced to conduct a Case Management - Legal/Non-compliance visit at 10:25 a.m. The purpose of today’s visit was to ensure the facility was maintaining substantial compliance as discussed in the Non-Compliance Conference that took place on 06/25/2025. As a result of the non-compliance conference, the Licensee is placed on frequent monitoring for a period of one (1) year. The LPA met with Kailey Vanderwall, Executive Director (ED) and Ketmany Nantavong Health Servies Director and explained the reason for the visit. During today’s visit, LPA focused on the physical plant / surrounding grounds. The LPA and ED toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: The facility is a double-story residence that consists of a memory care unit, and an assisted living unit. LPA observed fire extinguishers throughout the facility, which were fully charged and last serviced on 02/27/2025. LPA observed all the required postings in the Activity Room near the entrance area, and throughout the facility. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. Activities observed on both units. Common Areas: These included the beauty salon, library, activity room, theater, fitness center, bistro, and dining areas in assisted living and memory care units. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. Fireplaces were properly screened. LPA observed designated storage / utility rooms with emergency food and water. Report Continued on LIC 809-C PAGE 2 ... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 (PAGE 2) Report Continued from LIC 809-C... Surrounding Grounds (Outdoors) : The LPA observed appropriate outdoor furniture, with a covered shaded area for residents in both, the memory care unit courtyard and the assisted living courtyard. Parking is available for residents and visitors. Bedrooms: There are eighty -six (86) total apartments in the facility, fifty-nine (59) assisted living of which ten (10) are open studios, twenty-three (23) are one bedrooms, fifteen (15) are two (2) bedrooms, and eleven (11) studios with a double occupancy in the two (2) bedrooms, one (1) bedrooms, and open studios with a one hundred and seven (107) capacity. There are twenty-seven (27) apartments in memory care of which twenty one (21) are studios and six (6) are one (1) bedrooms with a double occupancy in the open studios, and one (1) bedrooms with a capacity of thirty- three (33) with a total capacity of one hundred and forty (140) in all. They are approved for eight (8) bedridden residents, and have a hospice waiver for fifteen (15). LPA observed ten (10) randomly selected resident bedrooms, (105, 107, 201, 243, 240, 229, 110, 114, 125A, 125B) of which six (6) in assisted living and four (4) in memory care. All resident bedrooms were properly furnished with at least one chair, nightstand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. All passageways were observed to be clear of obstructions. Restrooms: Resident restrooms appeared clean, sanitary and in operating condition with grab bars and to be equipped with a slip resistant surface / mat. The restrooms were sufficiently stocked with supplies and paper towels. Towels and washcloths are not shared among the rooms. The hot water temperature was measured and ranged between 105.3 - 110.0 degrees Fahrenheit all within the required range. Kitchen : The kitchen appeared clean and the appliances and fixtures functional. LPA observed a sufficient amount of perishable and non-perishable food at the facility. Food is prepared based on the menu. Snacks and beverages are available for residents in the dining area. Knives are stored and inaccessible to residents. Refrigerator and food pantry were checked for proper labels and expiration dates. Documents: Documents obtained during the visit include: Facility / Staff roster and a Resident roster. No citations issued. Exit interview conducted. Copy of report reviewed and provided.

(PAGE 2) Report continued from LIC 9099... During today's visit at 10:31 a.m. LPA and ED briefly toured the physical plant areas inside and outside to ensure there are no immediate health and safety hazards, and facility is in compliance with Title 22 Regulations. On the allegation, Staff did not provide authorized representative a refund after resident passed away, it is the concern of the Reporting Party (RP) that R1’s AR did not receive a full and accurate refund of the community fee and rent once R1 passed away. To investigate this complaint, LPA conducted in person interviews, telephonic interviews, corresponded via email, file and record review and obtained copies of pertinent documentation relevant to the investigation. Interview with the ED revealed that R1 moved into the facility on 06/30/2025 and fully moved out of the community with all belongings removed on 10/05/2025. R1 expired on 09/07/2025. The community hosted R1’s celebration of life on 09/28/2025 in the Bar & Lounge where R1’s belongings still remained in the community. The family gradually removed R1’s belongs with a date of 10/05/2025 documented as the official move out date. R1’s belongings remained in the community from 06/30/2025 to 10/05/2025 a total of 97 days as documented by facility records. The community policy states that after the 90 th day the community fee is non-refundable. The ED stated that the community strives to meet the needs of all residents and their families and acknowledges that this is a difficult time. As a courtesy to the family, the ED confirmed that they will honor the families proposed dates, which is not typical. The community fee refund will be re-calculated based on R1’s move-in date of June 30, 2025, through the expiration date of September 7, 2025, a total of 69 days. The community will issue a refund based on the initial fee of $6,000 , minus a $500 assessment fee . The refund will reflect 40% of that amount, which is $2,200. Additionally, the community will honor the families proposed move out date of September 11 th , 2025, as the end of rent date. The facility processed a one-time check dated 11/18/2025 in the amount of $10,359.24 reflecting the community fee adjustment to reflect 69 days, rent adjustment to reflect a move out date of 9/11/2025. Staff interviews revealed that R1 expired on 09/07/2025. R1’s belongings remained in the community after September 11 th and were completely removed at the end of September or beginning of October, the exact date is unknown. R1 had a majority of their big furniture items moved around September 11 th however small items remained in their apartment. Report continued on LIC 9099-C 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) Report continued from LIC 9099-C PAGE 2... R1 had a celebration of life at the community on 09/28/2025 and R1’s belongings were still in their apartment. R1’s family gradually removed R1’s belongings. Interviews with W1 revealed that AR hired their company to move R1’s belongings to a storage unit. The company moved R1’s belongings on 9/12/2025. The company typically moves large furniture items. The family was also taking things to their car at the same time. They are unsure if all belongings in the room were fully vacated on that day. Documents and Record review revealed that R1 moved into the community on 06/30/2025 and expired on 09/07/2025. R1 moved out of the community on 10/05/2025. R1 had their celebration of life at the community on 09/28/2025. Invoice dated 9/12/2025 indicated three (3) hours of service to move out R1's belongings. Documented conversation of 09/28/2025 indicated R1 still has items in their apartment. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Staff did not provide authorized representative a refund after resident passed away is deemed unsubstantiated at this time. Exit interview conducted. Report was reviewed and a copy was provided.

(PAGE 2) Report continued from LIC 9099... During today's visit at 10:31 a.m. LPA and ED briefly toured the physical plant areas inside and outside to ensure there are no immediate health and safety hazards, and facility is in compliance with Title 22 Regulations. On the allegation, Staff did not provide authorized representative a refund after resident passed away, it is the concern of the Reporting Party (RP) that R1’s AR did not receive a full and accurate refund of the community fee and rent once R1 passed away. To investigate this complaint, LPA conducted in person interviews, telephonic interviews, corresponded via email, file and record review and obtained copies of pertinent documentation relevant to the investigation. Interview with the ED revealed that R1 moved into the facility on 06/30/2025 and fully moved out of the community with all belongings removed on 10/05/2025. R1 expired on 09/07/2025. The community hosted R1’s celebration of life on 09/28/2025 in the Bar & Lounge where R1’s belongings still remained in the community. The family gradually removed R1’s belongs with a date of 10/05/2025 documented as the official move out date. R1’s belongings remained in the community from 06/30/2025 to 10/05/2025 a total of 97 days as documented by facility records. The community policy states that after the 90 th day the community fee is non-refundable. The ED stated that the community strives to meet the needs of all residents and their families and acknowledges that this is a difficult time. As a courtesy to the family, the ED confirmed that they will honor the families proposed dates, which is not typical. The community fee refund will be re-calculated based on R1’s move-in date of June 30, 2025, through the expiration date of September 7, 2025, a total of 69 days. The community will issue a refund based on the initial fee of $6,000, minus a $500 assessment fee. The refund will reflect 40% of that amount, which is $2,200. Additionally, the community will honor the families proposed move out date of September 11 th , 2025, as the end of rent date. The facility processed a one-time check dated 11/18/2025 in the amount of $10,359.24 reflecting the community fee adjustment to reflect 69 days, rent adjustment to reflect a move out date of 9/11/2025. Staff interviews revealed that R1 expired on 09/07/2025. R1’s belongings remained in the community after September 11 th and were completely removed at the end of September or beginning of October, the exact date is unknown. R1 had a majority of their big furniture items moved around September 11 th however small items remained in their apartment. Report continued on LIC 9099-C 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) Report continued from LIC 9099-C PAGE 2... R1 had a celebration of life at the community on 09/28/2025 and R1’s belongings were still in their apartment. R1’s family gradually removed R1’s belongings. Interviews with W1 revealed that AR hired their company to move R1’s belongings to a storage unit. The company moved R1’s belongings on 9/12/2025. The company typically moves large furniture items. The family was also taking things to their car at the same time. They are unsure if all belongings in the room were fully vacated on that day. Documents and Record review revealed that R1 moved into the community on 06/30/2025 and expired on 09/07/2025. R1 moved out of the community on 10/05/2025. R1 had their celebration of life at the community on 09/28/2025. Invoice dated 9/12/2025 indicated three (3) hours of service to move out R1's belongings. Documented conversation of 09/28/2025 indicated R1 still has items in their apartment. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Staff did not provide authorized representative a refund after resident passed away is deemed unsubstantiated at this time. Exit interview conducted. Report was reviewed and a copy was provided.

Licensing Program Analyst (LPA) Erica Mosley arrived at the facility at 10:04 a.m. to conduct an unannounced continuation of the annual inspection that began on October 23, 2025 (10/23/2025). Upon arrival LPA was greeted by front door receptionist and explained the reason for the visit. The LPA met with Executive Director (ED) Kailey Vanderwall and reason for the visit was explained. Entrance interview. During the annual inspection that was conducted on 10/23/2025 LPA Mosley conducted the full physical plant tour LPA observed the common areas, surrounding grounds / outdoors, nine (9) randomly selected resident bedrooms, of which six (6) in assisted living and three (3) in memory care, resident and community / public restrooms, kitchen, reviewed ten (10) personnel records, nine (9) resident records including home health and hospice records, and obtained pertinent documentation. During today’s visit, starting at 10:14 a.m. LPA conducted the entrance interview and a brief physical plant tour to ensure there are no immediate health and safety concerns, and facility is in compliance with Title 22 Regulations. The following was noted: The facility is a double-story residence that consists of a memory care unit, and an assisted living unit. There are eighty -six (86) total apartments in the facility, fifty-nine (59) assisted living of which ten (10) are open studios, twenty-three (23) are one bedrooms, fifteen (15) are two (2) bedrooms, and eleven (11) studios with a double occupancy in the two (2) bedrooms, one (1) bedrooms, and open studios with a one hundred and seven (107) capacity. There are twenty-seven (27) apartments in memory care of which twenty one (21) are studios and six (6) one (1) bedrooms with a double occupancy in the open studios, and one (1) bedrooms with a capacity of thirty- three (33) with a total capacity of one hundred and forty (140) in all. They are approved for eight (8) bedridden residents, and have a hospice waiver for fifteen (15). Report Continued on LIC 809-C PAGE 2 ... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 (PAGE 2) Report Continued from LIC 809-C... Facility Records: LPA reviewed the quarterly inspections, testing and maintenance reports for the wet pipe and fire sprinkler system conducted on 01/15/2025, 05/05/2025, and 07/16/2025 indicating a pass in all areas. The annual fire alarm system inspection report conducted on 07/16/2025 where all three- hundred -thirty-seven (337) smoke alarms, carbon monoxide detectors/ devices including but not limited to auxiliary, control, indicating, initiating, supervisory devices were tested, functioned properly, serviced and passed. The last twenty-four (24) hours of the alert system and pendant activity used by residents to alert staff for assistance was reviewed. The facility’s alert system includes a call button installed in every restroom and a pendant-style device worn as a necklace by residents. Both systems are integrated and designed to generate alerts that immediately notify staff when assistance is needed. The review revealed that, based on forty-four (44) recorded alerts, staff responded within one (1) to thirty- seven (37) minutes. LPA reviewed facility notes related to times that were longer than fifteen (15) minutes. The daily vehicle inspections, and annual Inspection report that was conducted on 03/05/2025 was reviewed for all facility vehicles. All records were in order. Infection Control / Emergency disaster planning: During today’s visit the LPA reviewed the facility’s infection control practices and the facilities emergency disaster plan. Both documents were observed to be complete and updated annually as required. The last emergency disaster drill took place on 09/4/2025 and conducted monthly covering all shifts and areas of emergency disasters. LPA reviewed the fire drill report conducted on 08/15/2025 at 10:45 p.m. in the memory care unit of a simulated fire in a resident room and a disaster drill on 08/15/2025 at 11 p.m. of a simulated extreme weather flooding both indicating a pass. The last in service training on infection control was conducted on 09/24/2025. The facilities policies and procedures, as they pertain to infection control and emergency planning meet the regulatory standard. Interviews: Starting at 1:26 p.m nine (9) staff interviews were conducted which indicated that staff are knowledgeable in resident rights, the various forms of abuse, and appropriate reporting procedures. Starting at 3:00 p.m. LPA conducted three (3) group interviews of eleven (11) residents total during the facilities OctoberFest festival. Group one (1) consisted of five (5) residents, group two (2) and three (3) consisted of three (3) residents each. Resident interviews revealed that no concerns were noted or expressed at the time of the visit. Residents reported that a variety of activities are offered and provided, and food substitutions are available upon request. Report Continued on LIC 809-C 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) Report Continued from LIC 809-C PAGE 2... Medication Audit: There are two (2) medication rooms located on each side of the facility. Med Techs distribute medication at the appropriate times to residents in care. Medication audit for nine (9) residents was conducted. Six (6) in the Assisted Living Unit and three (3) in the Memory Care Unit of which one (1) on Hospice. The following was observed. The medications were stored in the medication rooms in carts, both were locked and inaccessible to the residents. Medications are labeled and checked for expiration dates. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications reviewed were found to be self-administered as prescribed and documented on the centrally stored medication and destruction records. LPA advised ED that a few of the start dates were difficult to read and suggested reviewing / clearing up the writing to make it easily legible. No errors observed during review. Documents: Documents obtained during the visit include: Limited Liability insurance. LPA obtained the following documents on the initial annual visit on 10/23/2025 : Facility / Staff roster and a Resident roster. During today's inspection, the facility is in compliance with Title 22 regulations. No citations issued. Exit interview conducted. Copy of report reviewed and provided.

Licensing Program Analyst (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit at 10:00 a.m. Upon arrival LPA was greeted by front door receptionist and explained the reason for the visit. The LPA met with Executive Director (ED) Kailey Vanderwall and reason for the visit was explained. Entrance interview. The LPA and ED toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: The facility is a double-story residence that consists of a memory care unit, and an assisted living unit. LPA observed fire extinguishers throughout the facility, which were fully charged and last serviced on 02/27/2025. LPA observed all the required postings in the Activity Room near the entrance area, and throughout the facility. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. Activities observed on both units. In the Memory Care until morning exercise, and daily chronicles were observed. Common Areas: These included the beauty salon, library, activity room, theater, fitness center, bistro, and dining areas in assisted living and memory care units. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. Fireplaces were properly screened. LPA observed designated storage / utility rooms with emergency food and water. Surrounding Grounds (Outdoors) : The LPA observed appropriate outdoor furniture, with a covered shaded area for residents in both, the memory care unit courtyard and the assisted living courtyard. Parking is available for residents and visitors. Report Continued on LIC 809-C PAGE 2 ... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 (PAGE 2) Report Continued from LIC 809-C... Bedrooms: There are eighty -six (86) total apartments in the facility, fifty-nine (59) assisted living and twenty-seven (27) in memory care. LPA observed nine (9) randomly selected resident bedrooms, of which six (6) in assisted living and three (3) in memory care. All resident bedrooms were properly furnished with at least one chair, nightstand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. All passageways were observed to be clear of obstructions. Restrooms: Resident restrooms appeared clean, sanitary and in operating condition with grab bars and to be equipped with a slip resistant surface / mat. The restrooms were sufficiently stocked with supplies and paper towels. Towels and washcloths are not shared among the rooms. The hot water temperature was measured and ranged between 106.0 - 120.0 degrees Fahrenheit all within the required range. LPA advised ED of the regulatory standard of 105-120 degrees Fahrenheit as the water was at the maximum. Kitchen : The kitchen appeared clean and the appliances and fixtures functional. LPA observed a sufficient amount of perishable and non-perishable food at the facility. Food is prepared based on the menu. Snacks and beverages are available for residents in the dining area. Knives are stored and inaccessible to residents. Refrigerator and food pantry were checked for proper labels and expiration dates. Records: Personnel Records were reviewed beginning at 11:53 a.m. Ten (10) Personnel files including the ED's file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order. Resident Records were reviewed beginning at 1:05 p.m. Nine (9) Resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All records were in order. DOCUMENTS: Documents obtained during the visit include: Facility / Staff roster and a Resident roster. Due to time constraints the LPA will return to complete the annual at a later date. Exit interview conducted. Copy of report reviewed and provided.

Regarding the allegation, "Facility staff failed to contact POA regarding medical emergency" it is the concern of the reporting party (RP) that On 7/17/2025, Resident 1 (R1) was sent to St. John's Regional Medical Center due to a rash on their face (suspected shingles), however when the facility staff sent R1 to the hospital they did not notify the POA. To investigate the allegation the LPA conducted interviews and a file review. Interview with R1's Power of Attorney (POA) revealed that they were notified of R1's hospital visit however it was after R1 was already admitted to the hospital, and that the hospital would not release any information to them due to the hospital not being provided their information. R1's POA stated they did receive three calls from facility staff about the incident and it could have been the same day R1 was taken to the hospital but after they were already admitted. Interview with Staff 1 (S1) revealed that they attempted to contact R1's POA however the Resident Information form used at the time of R1's hospital visit had the wrong POA listed. They were able to get R1's POA contact information and do not recall the exact date but recall speaking to them. In addition they stated that residents are still to be attended in emergency situations regardless if they were able to successfully contact the POA. A review of R1's Inpatient Discharge Instructions from St. John's Regional Medical Center revealed that R1 was taken to the hospital on 07/21/25 which was the date confirmed by R1's POA that they were notified of the incident. Based on interviews and records reviewed this allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted and report provided to the Executive Director. 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 was amended. Amended report emailed for signature. Signature on file. Regarding the allegation, "Facility staff failed to provide hospital with POA contact information"; it is the concern of the Reporting Party (RP) that On 7/17/2025, Resident 1 (R1) was sent to St. John's Regional Medical Center due to a rash on their face (suspected shingles), however staff did not provide R1’s POA contact information to the hospital. To investigate the allegation the LPA conducted interviews and a file review. Interview with R1's Power of Attorney (POA) revealed that they were notified of R1's hospital visit after R1 was already admitted to the hospital, and that the hospital would not release any information to them due to the hospital not being provided their information. Additionally, the POA revealed that if they had been notified sooner of the hospital visit they would have asked for R1 to be taken to a different hospital. Interview with Staff 1 (S1) revealed that the Resident Information form used at the time of R1's hospital visit had the wrong POA listed. When the LPA showed S1 the form that was provided to the LPA as part of the emergency packet, S1 revealed that was not the same form used the day of the hospital visit. S1 indicated that they called the "POA" that was listed on the previous Resident Information form and when they answered they notified them that they would like to be taken off as R1's "true POA" and provided S1 with R1's actual POA. S1 attempted to call R1's actual POA with the information provided to the them but did not leave a voicemail with sensitive information due to not knowing if that was actually R1's POA. S1 further revealed that they recall giving the actual POA's phone number to the paramedics on a sticky note. Lastly, it was revealed that the Regional Memory Care Director updated their system with the correct POA information after the incident and a new face sheet was printed. On 07/28/25, LPA Cortez was notified by Witness 1 (W1) that in 2023, R1's POA shared their contact information and POA paperwork with the staff and W1 shared it with them as well. File review revealed that R1 has a Power of Attorney for Health Care on file with the correct POA listed on file. The LPA also observed a Resident Information form on file with a primary and second emergency contact, which were not the POA. Based on staff interview and file review, there is sufficient evidence to support the allegation and that a violation occurred; therefore, the above allegation is deemed Substantiated at this time. The following deficiency was cited from the CA Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview held, appeal rights and report copy provided.

Regarding the allegation, “Staff does not ensure resident's medical needs are being met”; it is the concern of the Reporting Party (RP) that Resident 1 (R1) has been diagnosed with lymphedema and has peripheral neuropath prior to admission to the facility and was scheduled for two appointments with the Physician from the facility but the Physician cancelled both appointments. It was further alleged that R1 does not need to go to the hospital but needs more hands-on care from facility staff, R1 sustained a fall and their lymphedema was triggered and R1 has asked for more help but staff does not help. The LPA reviewed records which indicated R1 was receiving medical care with physicians. R1 received home health services at the facility. R1 received assistance from care staff as well. Interviews with staff and charting notes confirmed R1 was receiving care, however oftentimes R1 would refuse care or refuse to go to scheduled appointments. Interviews with other residents confirmed they receive the care they need from staff and stated all of their care and medical needs were met. Based on interviews and records reviewed this allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation, “Staff does not ensure resident's medications are refilled in a timely manner”; it is the concern of the Reporting Party (RP) that on 03/23/25, Resident 1 (R1) needed their topical medication for their hands and toes but the Med Tech didn’t have any to give to them because the staff did not refill R1’s medication on time. Staff interviews revealed that they submitted refills on time, denied R1 was ever without medication due to the community not refilling them on time. However, R1 has orders for topical medications that can be self administered and remain at bedside with R1 and R1 will not notify MedTechs that their medications will be running out soon and often notify MedTechs they need a refill once the medications are already done. Additionally, file review revealed that R1 has a history of being non-compliant with medications and has a history of refusal of medication. There was no indication that mediations were not refilled on time by staff during file review. Lastly, all interviews with residents revealed that they have no concerns regarding medications not being refilled on time. Based on interviews and records reviewed this allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted. Report provided.

Regarding the allegation, “Staff isolates resident in room” it is the concern of the Reporting Party (RP) that on or about 05/31/24, Resident 1 (R1) was diagnosed with scabies and the facility isolated the resident for four weeks. File review revealed that on 05/30/24, staff made R1’s Primary Care Physician (PCP) aware of scabs/sores on R1’s back via email by sending them photos of R1’s back and asked to “please advise”. Once R1’s PCP advised that scabies treatment would be ordered, staff asked if they should take scabies precautions and isolate R1 to which R1’s PCP replied with “Until treatment ideally.” Staff then notified the PCP, that their corporate office was having R1 isolate and release with MD clearance after treatment. PCP responded that they would order HH so they could give clearances after treatment. LPA Cortez observed a doctor’s order for R1 to come off isolation by their PCP, dated 06/26/24. Additionally, interviews conducted with Executive Director Kailey Vandewall, Memory Care Director Denise Wadkins, and Health Services Director (HSD) Ian Gadea on 07/25/24, by LPA Camera, revealed that R1 was placed in isolation due to possible scabies, the doctor told them to isolate the residents to prevent spread to others. In addition, they followed Oakmont protocol for scabies which states to follow doctors orders. Interviews conducted with ED Kailey by LPA Cortez revealed that even though R1 was placed in isolation, they were still continuing the same care it just looked a bit different, staff made sure to be using the proper PPE, and R1 had a 1:1 with them during this period. Although the allegations may have happened or is valid, there is not sufficient evidence to prove that a violation occurred, therefore the allegation is deemed Unsubstantiated at this time. Regarding the allegations. “Staff does not ensure resident is provided toiletry supplies, and Staff does not ensure resident's hygiene needs are being met,”; it is the concern of the Reporting Party (RP) that in 2024, R1 was not being provided toilet paper due to clogging the toilet, and that R1 was unkempt and needed increase care with toileting and showering. To investigate the allegation the LPA visited R1 and conducted interviews. On 05/21/25, 05/22/25, and 07/16/25 the LPA observed R1’s restroom with toilet paper accessible to the resident. On 05/21/25, and 05/22/25 the LPA observed R1 to have a neat and well-maintained appearance. Additionally, on 05/21/25, an interview conducted with R1 revealed that they have no concerns, staff help them and treat them well . Report will continue on LIC9099-C 3rd page. 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 Most of the staff interviews revealed that they have never seen R1 unkempt, and they have never seen R1’s bathroom without toilet paper unless they run out and there is additional supply of toilet paper in a locked closet inside the resident’s room. The information obtained during the investigation did not include sufficient evidence to corroborate the allegations. Although the allegations may have happened or are valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegations are deemed Unsubstantiated at this time On the allegation, “Staff does not safeguard resident's personal belongings” it is the concern of the Reporting Party (RP) that Resident 1 (R1) had a lot of expensive clothing brand and on or about 5/30/24, R1 was diagnosed with scabies, and isolated. During this time most of R1’s clothing and bedding was placed in plastic trash bags to be laundered separately in hot water, and the facility lost most of R1’s clothing and bedding or shrunk their clothing. Most of the staff interviewed revealed that they had no knowledge of any missing items for R1, and all clothing and bedding that was laundered were returned. All care staff interviewed denied ever losing or taking any of R1’s belongings. Interviews conducted with ED Kailey revealed that all items were placed back, however there were some clothing that did shrink due to being laundered in hot water, which was part of the Oakmont protocol for Scabies. Additionally, the ED stated that they have offered R1’s POA the opportunity to give the ED a list of items (and their value) that they believe were missing or shrunk and the ED would work with them in processing a refund. File review revealed that R1’s signed Admission Agreement and the facility’s Theft and Loss Policies and Procedures indicate that the facility will maintain an inventory of personal property upon request, unless the resident or responsible party does not wish to complete the inventory. Additionally, the Theft and Loss Policies and procedures indicate that the facility reports lost items of $100 or more to law enforcement and investigate missing items. File review revealed that R1’s responsible party indicated they do not wish to inventory any personal property. Although the allegations may have happened or are valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegations are deemed Unsubstantiated at this time. Exit interview conducted. 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 Regarding the allegation, “Staff does not ensure resident's bathroom is clean”; it is the concern of the Reporting Party (RP) that feces on R1’s bathroom floor was observed. One staff member confirmed that on more than one occasion they saw feces on the floor of R1’s bathroom that looked dry as if it had been there for an extended period and has questioned colleges as to why they did not clean it during previous shifts. On 07/16/2025, the LPA toured R1’s locked bedroom including their bathroom with Executive Director Kailey and at 3:51 p.m. observed dry feces in R1’s bathroom floor, toilet bowl seat with brown skid marks, and the yellow urine stains in the front of the toilet base. Based on the information gathered, the Department has sufficient evidence to support the allegation, therefore the allegation Staff does not ensure resident's bathroom is clean is Substantiated at this time. The following deficiency was cited from the CA Code of Regulations, Title 22 (See LIC9099-D.). Failure to correct the deficiencies may result in civil penalties. Exit interview conducted, appeal rights and report copy provided.

Regarding the allegation, “Resident lost significant amount of weight”. It is the concern of the Reporting Party (RP) that on or about 05/31/24, Resident 1 (R1) was diagnosed with scabies and the facility isolated the resident for four weeks. During the isolation period the resident lost a lot of weight, from about 112 lbs. R1 dropped to 103 lbs. and went from a size 6 to a size 2. File review revealed that Resident #1 (R1) was admitted to the facility on 1/13/24. Per R1’s Monthly Vital Signs and Weight Record, on 1/25/24, R1 weighed in at 121 lbs. and on 07/25/24 (shortly after the complaint was submitted), R1 weighed in at 108 lbs. This is a 13 lbs. weight loss within a 6-month period. Furthermore, R1 weighed in at 114 lbs. on 5/31/24, having a 6 lbs. weight loss within 2 months. The community’s Charting Notes starting on 5/17/2024 and ending on 08/05/2024 indicated that during that time frame R1 was being treated for Scabies, placed on isolation on 05/30/24 until MD gives clearance to leave, on 06/26/24 an order was received from residents PCP that R1 was able to come off isolation, and on 07/06/24 PCP was notified that R1 will be in isolation. However, R1’s charting notes did not reflect any doctor appointments to address the issues with weight loss, additionally no mention of weight loss was charted on these notes. Interview conducted by LPA Camara with the ED on 07/25/24, revealed that the ED was not aware R1 had lost so much weight and suspected it could have been muscle loss due to the isolation period because R1 is normally quite active, and the ED planned on asking R1’s doctor if they should put R1 on Ensure to get some weight back on them. Interview conducted by LPA Camera with R1’s Primary Care Physician (PCP) revealed that they do not weigh the resident because they are mobile, but that they had not realized R1 had lost that weight and was not aware of a medical cause for the weight loss. File review did not indicate any notification of weight loss to R1’s PCP by the community. During today's visit, Business Office Director was not able to provide any records of staff addressing R1's weight loss in 2024 with their PCP. Based on file review and interviews, the Department has sufficient evidence to support the allegation, therefore the allegation Resident lost significant amount of weight is Substantiated at this time. The following deficiency was cited from the CA Code of Regulations, Title 22 (See LIC9099-D.). Failure to correct the deficiencies may result in civil penalties. Exit interview held, appeal rights and report copy 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 Regarding the allegations, “Resident contracted scabies while in care and Resident developed sores while in care”; It is the concern of the Reporting Party (RP) that on or about 05/31/24, Resident 1 (R1) was diagnosed with scabies and R1 had scabs/sores on their back from scratching. File review revealed that on 05/30/24, R1’s Primary Care Physician (PCP) was notified that R1 was noted scratching chest, upper/lower back, small dry red/brown spots were noted, pictures were sent over, and PCP was asked to please advise. Interviews with the ED, staff, R1’s PCP and charting notes revealed that R1 was diagnosed with Scabies/suspected Scabies on 05/30/24 by their Primary Care Physician and was prescribed treatment. File review revealed that staff addressed R1’s rash and were following R1’s orders. The ED revealed that R1’s Power of Attorney (POA) made different Dermatology appointments and R1’s reoccurring rash ended not being scabies. Interview conducted with R1’’s POA revealed that the error came from R1’s PCP who misdiagnosed R1 with Scabies, they took R1 to several Dermatologist and R1 had a bacterial infection and recovered after they were given antibiotics. A review of an Urgent Care Center doctors order dated 08/01/24, indicated that R1 did not have a rash due to scabies. Information obtained from file reviewed and interviews conducted revealed R1 was diagnosed with Scabies/possible scabies and presented a rash on their back, however R1 was being seen and treated by their PCP. Staff interviews also revealed that staff was following facilities Scabies protocol, and all doctor’s orders. Therefore, the allegations are deemed Unsubstantiated at this time. Exit interview conducted and report issued.

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management – Incident visit to the above facility. The LPA met with Executive Director Kailey Vanderwall and explained the reason for the visit. Entrance interview conducted. The reason for today's inspection is to follow up on a self-reported death report received on 03/11/2025. The report pertains to the death of Resident #1 (R1). It was reported R1 was sent to the hospital on February 23th due to a fall and passed away on March 8th at the hospital. During today's visit, the LPA conducted an interview with the Executive Director, Health Service Director, one (1) resident, conducted a brief tour of the facility and obtained copies of pertinent documents. Further investigation is required prior to issuing findings. Exit interview conducted. A copy of the report was issued to the Executive Director.

Report continued from LIC9099.... On the allegations, “Facility staff spoke inappropriately to resident, Facility staff refused to assist resident with mobility, Facility staff refused to assist resident with dressing”; it was alleged that two (2) staff (S1, S2) called Resident 1 (R1) “fat”, “heavy”, and “disgusting,” refused to help R1 with mobility issues such as getting out of bed and refused to help change their clothes. Date was not provided. Interview conducted with R1 on 11/29/2023 revealed that they were confronted by a couple of workers in a mean way, staff told R1 to get ready and get dressed, however R1 is not able to do it by themselves. R1 further revealed that they have a problem with their memory and could not remember their names. Interviews conducted with staff revealed that S1 is no longer at the community and there is no staff with the name provided for S2 currently working at the community or during the time the complaint was submitted in November of 2023. All care staff denied speaking to any resident inappropriately and denied they have refused to assist residents. Three (3) out of thirteen (13) staff interviewed revealed that R1 voiced concerns to them about the above allegations, and have observed similar behavior from staff, however, all thirteen (13) staff revealed that they did not witness the noted allegations. Six (6) residents interviewed revealed that they have never been denied assistance or talked to inappropriately by any staff. On the allegations, “Facility staff spoke inappropriately to resident, Facility staff refused to assist resident with mobility, Facility staff refused to assist resident with dressing”; information gathered from interviews revealed that all care staff denied allegations, there is no staff by the name provided for S2, R1 could not remember the names of the staff when interviewed by the LPA, there were no witnesses, and six (6) other residents interviewed revealed they had no concerns. Based on interviews, although the allegation may be valid, at this time, there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegations above are deemed UNSUBSTANTIATED at this time. Exit interview conducted. Today's report was reviewed and emailed to the Executive Director.

Licensing Program Analyst (LPA) Erica Mosley conducted an unannounced continuance Inspection of the above-named facility. LPA was greeted by the front door receptionist and called Business Office Director (BOD) - Ricardo Viveros and Health Services Director (HSD) - Ian Gadea and explained the reason of the visit. The Administrator Kailey Vanderwall was not able to attend due to training and designated staff to sign the report. At approx. 9:30a.m. LPA Mosley conducted a tour of the physical plant with Health Services Director and Business Office Director to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The following was noted: Facility is a double-story residence that consists of a memory care unit, and an assisted living unit. LPA observed fire extinguishers throughout the facility, which were fully charged and last serviced on 12/19/2023. On the initial visit on 09/28/2024 the Administrator provided a monthly fire alarm testing and inspection report done on 08/27/2024 where all smoke alarms and carbon monoxide detectors were tested and functioned properly. The last emergency disaster drill took place on 10/24/2024 and 10/31/2024 to cover both shifts and are conducted quarterly. LPA observed all required postings in the Activity Room near the entrance area. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. Activities observed on both units. In the Memory Care until at approx. 9:45am, morning movie was observed with about ten (10) to fifteen (15)residents in attendance. In the Assisted Living unit at approx. 11:00am. Paws for Love (therapy dog activity) was observed with about six (6) residents in attendance. Report Continued 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 Report Continued from LIC 809... RECORDS: PERSONNEL FILES: were reviewed beginning at 10:25 a.m. for eight (8) staff including the Business Office Director , and Health Services Director . Files were reviewed for, but not limited to personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order at the time of the visit. RESIDENT RECORDS: were reviewed beginning at 11:26 a.m. for eight (8) residents. Files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All files were in order at the time of the visit. During today's inspection, the facility is in compliance with Title 22 regulations. No citations issued. LPA obtained the following documents - Resident roster and Staff roster. Exit interview conducted. Copy of report provided.

Licensing Program Analysts (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit at 9:15 a.m. Upon arrival LPA were greeted by front door receptionist and explained the reason for the visit and to call their administrator. LPA met with Lace Szelesteywoodfi, Sales and Marketing Coordinator and Executive Director (ED) Kailey Vanderwall who arrived later during the visit. The reason for the visit was explained. At approx. 9:30a.m. LPA Mosley conducted a tour of the physical plant with Sales and Marketing Coordinator to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The following was noted: Facility is a double-story residence that consists of a memory care unit, and an assisted living unit. LPA observed fire extinguishers throughout the facility, which were fully charged and last serviced on 12/19/2023. The Administrator provided a monthly fire alarm testing and inspection report done on 08/27/2024 where all smoke alarms and carbon monoxide detectors were tested and functioned properly. The last emergency disaster drill took place on 07/26/2024 and conducted quarterly. LPA observed all required postings in the Activity Room near the entrance area. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. Activities observed on both units. In the Memory Care until at approx. 9:30am, morning exercise was observed. In the Assisted Living unit at approx. 11:15am. painting was observed. Report Continued 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 Report Continued from LIC 809... Kitchen : During the facility tour, at 9:56am the kitchen appeared clean and the appliances and fixtures functional. LPA observed a sufficient amount of perishable and non-perishable food at the facility. Food is prepared based on the menu. Snacks and beverages are available for residents in the dining area. Knives are stored and inaccessible to residents. Refrigerator and food pantry were checked for proper labels and expiration dates. Bedrooms: During today’s visit from approx. 10:01am to 10:45am, LPA observed eight (8) randomly selected resident bedrooms, of which five (5) in Assisted Living and three (3) in Memory Care. The resident bedrooms were properly furnished with at least one chair, night stand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. Restrooms: The resident restrooms appeared clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared in the private rooms. The hot water measured between 107.1 – 119.9 degrees Fahrenheit all within the required range. Common Areas: These included the beauty salon, library, activity room, theater, fitness center, bistro, and dining areas in assisted living and memory care units. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. Fireplaces were properly screened. Surrounding Grounds (Outdoors) : The LPA observed appropriate outdoor furniture, with a covered shaded area for residents in both, the memory care unit courtyard and the assisted living courtyard. Parking is available for residents and visitors. Infection Control / Emergency disaster planning: During today’s visit the LPA Mosley reviewed the facility’s infection control practices and the facilities emergency disaster plan. The facilities policies and procedures as it pertains to infection control are adequate. Daily vehicle inspection list and California Highway Patrol Inspection report was reviewed for facility vehicles. All records were in order. Report Continued 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 Report Continued from LIC 809... Interviews: LPA conducted six (6) resident interviews from approx. 10:20am- 11:10am and six (6) staff interviews from approx. 11:15am- 11:40am. MEDICATION AUDIT: There are two (2) medication rooms located on each side of the facility. Med Techs distribute medication at the appropriate times to residents in care. Medication audit for five (5) residents was conducted. Three (3) in the Assisted Living Unit and two (2) in the Memory Care Unit. The following was observed. The medications were stored in the medication room in carts, both were locked and inaccessible to the residents. Medications are labeled and checked for expiration dates. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. No errors observed during review. Due to time constraints the LPA will return to complete the annual at a later date. During today's inspection, the facility is in compliance with Title 22 regulations. No citations issued. LPA obtained the following documents - Resident roster, LIC 500, and copy of the Limited Liability insurance. Exit interview conducted. Copy of report provided.

Continued from LIC 9099-C Following is a summary of the investigation findings: Regarding allegation, “Staff did not notify resident’s responsible party of an incident” – it was alleged that Resident #1 (R1) sustained a fall at the facility on June 22, 2023, a week after admission and the responsible party was not informed. Staff interviewed revealed that R1 was admitted on 06/13/2023 and did sustain two (2) falls on or about 06/22/2023 and another in 08/23/2023. Staff interviews and records reviewed confirmed that the 06/22/2023 fall was not reported to the responsible person or the department. Based on the above information gathered, there is sufficient evidence to support the allegation of “Staff did not notify resident’s responsible party of an incident”. Therefore, the allegation is deemed SUBSTANTIATED at this time. Regarding allegation, “Staff did not communicate with resident's family regarding increase in medication” – Information was received that facility staff requested a medication change from R1’s doctor without obtaining consent from R1’s responsible party. Records reviewed and interviews conducted with staff on 09/13/2023 revealed that between 6/24/2023-8/24/2023, R1’s was exhibiting behavioral issues which was reported to the doctor and therefore the seroquel medication was increased. Staff interviewed and records reviewed confirmed that R1’s seroquel medication was increased from 50mg to 75mg then to 100mg. Interview with staff revealed that R1’s change in condition since move-in and medication changes were not communicated to R1’s responsible person. Based on the above information gathered, there is sufficient evidence to support allegation “Staff did not communicate with resident's family regarding increase in medication”. Therefore, the allegation is deemed SUBSTANTIATED at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies was cited (refer to LIC 809-D): Exit interview conducted. A copy of the 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 Continued from LIC 9099 Regarding allegation, “Staff did not seek medical attention for a resident in a timely manner” - The complainant alleged that Resident #1 (R1) was observed with a swollen arm and staff did not seek timely medical attention. Interview with staff and record reviewed confirmed that staff were notified that R1’s right arm was swollen by R1’s responsible person on 07/17/2024 and a tele-visit was conducted with R1’s doctor. Staff interviewed reported that prior to 7/17/2023, R1’s arm was not observed to be swollen. Following the tele-visit on 07/17/2023, R1’s doctor order an x-ray; which was conducted at the facility once the order was approved. X-ray of R1’s arm did not reveal any issue. R1 was a resident in the memory care unit and has since passed away. Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the above allegation “Staff did not seek medical attention for a resident in a timely manner” is deemed UNSUBSTANTIATED at this time. Regarding allegation, “Resident hygiene needs not met” - It was alleged that R1 was not cleaned up after a bowl incident (date unknown) and was observed with dry feces on the hand the following day. Staff interviewed denied the allegation and expressed that if a resident is in the room resident is checked on at least every two hours by staff. Staff interviewed reported that residents are not left unattended and are checked on and cleaned regularly. Staff denied allegation and stated that resident are kept clean and odor free. Staff expressed that resident do have accidents and are cleaned immediately when observed. Facility common areas, and random resident rooms were toured in the assisted living and memory care on 9/13/2023, and 10/24/23. During these visits, residents and common areas did not observe to be unkept. R1 was a resident in the memory care unit and has since passed away. Based on the above gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the above allegation “Staff leaves residents unattended” is deemed UNSUBSTANTIATED at this time. Continued on LIC 9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Continued from LIC 9099-C Regarding allegation, “Staff are taunting resident” - Information was received that during the firsts two weeks of move-in R1 was observed having a volatile episode and “nurses” (names unknown) observed laughing at R1. Random staff interviewed denied witnessing any “nurses” laughing at or taunting R1. No other witnesses to the alleged was reported. Interview was attempted with random resident in the memory care unit however residents were unable to effectively communicate with LPA due to loss of level of cognitive abilities. A few random residents who were greeted by LPA did express that they like the staff and are not mistreated. R1 was a resident in the memory care unit and has since passed away. Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the above allegation “Staff are taunting resident” is deemed UNSUBSTANTIATED at this time. Exit interview conducted and copy of report provided.

Investigator Real conducted interviews on 09/21/2023, from approximately 11:30 a.m. to 2:30 p.m., with the Business Office Director and residents; and on 10/24/2023 with staff. Additionally, investigator Real reviewed facility file documents related to R1 and R2, and contacted the Oxnard Police Department who did not investigate the matter after it was determined no crime occurred and no police report was generated. A review of R1’s physician report, dated 10/28/2021, indicates a primary diagnosis of dementia, psychosis, and hypertension. Mental conditions are listed as confused, disoriented delusions at times. R1 needs stand-by assistance with all activities of daily living. A review of R2’s physician report, dated 06/14/2021, indicates a primary diagnosis of Parkinson’s disease. No dementia or mild cognitive impairment was noted. R2 has the capacity for all self-care needs and is able to store and administer their own medications. On 03/06/2020, R1 and R2 were admitted to the assisted living section of the facility. On 11/30/2022, when R1’s needs changed, R1 was admitted to the memory care section of the facility. The investigation revealed that R1 and R2 have been married for 53 years. R2 has dinner with R1 in the memory care section of the facility every night and after dinner they go back to R1’s room where they spend time together until R1 goes to bed. According to the Business Office Director, they witnessed R1 and R2 together in bed sometime in June 2023. Sometime between 6:00 p.m. and 6:30 p.m., a staff requested the director to meet them at R1’s room. Through the door they could hear R1 talking with R2 and heard R1 say “I’m not comfortable”. The director was not sure of the context of the statement, so they entered the room and observed R1 and R2 in bed and covered with a sheet. The director asked R1 if they were okay and R1 responded “yes, I’m okay.” The director did not observe any cuts or injuries on R1’s arms or anywhere else on R1’s body. R1 did not have any concerns with R2 being in the room and wanted R2 to remain with R1 in the room. R1 did not report any problems or concerns to the director and wanted them to leave. R2 also asked them to leave, the director and the staff then left after determining nothing was wrong. The resident care notes dated 06/21/2023 and 06/22/2023, document that R1 and R2’s resident representative was contacted to discuss intimacy, safety and privacy. R1 and R2’s resident representative was supportive of R1 and R2 being together alone in R1’s room and had no concerns. The resident care notes further document that on 06/13/2023, R1 was noted to have a skin tear to lower left arm and treated by staff. Home health services was contacted and redressed the wound on 06/16/2023. (Continue to 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 The interviews conducted with R1, R2, other residents and staff during the complaint investigation did not indicate R1 suffered any physical or sexual abuse from R2. R1 and R2 denied the allegation. R1 and R2’s resident representative was supportive of R1 and R2 being together alone in R1’s room and had no concerns. The residents interviewed felt safe in the facility and had no complaints or problems to report. No one reported any neglect or lack of care or supervision. The facility staff denied the allegation and felt the level of care provided to the residents was appropriate. The information and evidence obtained did not sufficiently support the allegation, therefore the allegation “Neglect/Lack of Supervision: Facility staff failed to provide an appropriate level of supervision which resulted in Resident #1 (R1) being sexually and physically assaulted by Resident #2 (R2)” is deemed Unsubstantiated at this time. Exit interview conducted, copy of this report issued.

According to reporting party (RP), in the video, S1 and S2 were mocking and ridiculing R1. This was brought to the attention of the Executive Director and Memory Care Director. RP was unsure whose cell phone it was recorded on or if the video was posted. The video recording was shown to staff in the facility's break room. The video was taken in the memory care unit in R1’s bathroom. Both S1 and S2 were seen on the video with R1, making fun of R1 in the recording. LPA interviewed six (6) staff on 2/9/2023 between 11:30AM to 3:45PM. Conflicting information was provided by staff. S1 and S2 denied that they ever recorded R1 in the shower or that they ever mocked and ridiculed R1. Both S1 and S2 reported that they do take pictures with residents and record sometimes with families consent to share with families. Two out of the six staff interviewed reported seeing this video. One staff reported it was a video and audio recording and S1 and S2 were making fun of R1, mocking and ridiculing R1 in the video. Another member of staff reported that they did see a video however there was no audio. This staff stated that R1 was seen in the video with back to the camera getting in the shower. Staff stated that the only thing you can see was the back of R1’s head nothing else. Four other staff named as witnesses interviewed denied ever seeing any video recording in the break room of R1. LPA discussed this allegation with the ED. Furthermore, it was explained that the alleged video recording was reported by concerned staff. An internal investigation was conducted, and staff were interviewed by the ED. Staff interviewed denied the allegation. No staff came forward about seeing this video in the facility break room to corroborate the allegations. ED mentioned that a meeting was held with all memory care unit staff regarding facility house rules, policies and procedures were reviewed. Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegations or that a violation occurred; therefore, the above allegations “Staff video recorded resident without permission and Staff mocked resident” is deemed UNSUBSTANTIATED at this time. Regarding allegation “Staff speak to residents disrespectfully” – RP expressed concerns about the Memory Care staff at the facility. RP reported that about a week ago, resident #2 reported to RP that S3 called R2 an "idiot." RP claims that R2 is cognitively aware, and this wasn’t the first time this resident reported verbal abuse by this same staff. RP stated that this was reported to the Memory Care Director, but nothing came of it. RP has heard the same staff last year in the dining room speaking to residents in rude condescending way and it was reported to the former Director and Health Services Director (HSD) at the time. RP also stated that the memory care unit HSD, S1 and S2 are also often disrespectful and rude. Staff interviews conducted revealed conflicting statements. Staff interviewed denied the allegation. (Continue to 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 LPA attempted to interview residents in the memory care unit. Random residents approached did not respond to LPA’s greeting to converse with LPA. Residents did not comprehend basic questions asked. LPA was able to interview a visitor at the facility on 02/09/2023 and they reported that they are at the facility at least 2-3 times a week and have not observed any staff to be disrespecting or rude with residents. Attempt was made to reach former staff on 11/1/2023, 11/13/2023 and 11/14/2023. Other potential witnesses interviewed on 11/13/2023 expressed that they like the facility and they have not observed/witness any staff to be disrespectful or rude to residents in care. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the above allegation “Staff speak to residents disrespectfully” is deemed UNSUBSTANTIATED at this time. Exit interview conducted. A copy of the report was provided.

(Report Continued from LIC 9099...) It was alleged that staff handled resident roughly. It was reported that staff was giving Resident #1 (R1) a sponge bath and cleaning them even after R1 was screaming in pain. Information obtained from R1’s Physician’s Report (LIC 602A) dated 09/14/2022, indicated R1 was confused/disoriented and expressed aggressive behavior; however, it also indicated R1 was able to follow instructions and communicate needs. Interviews conducted with staff revealed residents are vocal and will report if either staff or anyone else treats them differently. Additionally, staff stated they have not witnessed another staff be rough or aggressive with any resident. Interviews with family members revealed the residents have not reported any type of mistreatment from the facility staff and stated they had no concerns. Furthermore, residents stated the staff is nice and treat the residents right and denied staff has either been rough or aggressive while helping them. Based on the information obtained during the course of the investigation, the Department does not have sufficient evidence to support the allegation of “staff handled resident roughly”. Therefore, this allegation is deemed Unsubstantiated at this time. It was also alleged that staff are not properly trained. It was reported that staff was not trained properly in how to deal with hospice residents and to not touch/move the resident due to pain. Record review revealed that upon hiring, facility staff are trained through Relias Learning, LLC. Once all online based training is completed, staff will undergo at least three days of shadowing another staff to ensure proper training. Additionally, R1’s Resident Assessment dated 08/11/2022, stated resident requiring services from hospice staff will have care provided by the facility nurse. Interviews conducted with staff revealed they receive training as soon as they are hired and continuously receive training as needed. Interviews conducted with family members revealed the residents depend on the staff to assist with their activities of daily living (ADL’s) and feel the residents’ needs are being met. Furthermore, family members stated they had no concerns about the staff and reported feeling sure the facility staff is trained and know what they are doing. Based on the information and records obtained and reviewed, the Department does not have sufficient evidence to support the allegation of “staff not properly trained”. Therefore, this allegation is deemed Unsubstantiated at this time. Exit interview conducted. No citations were issued at this time. Report was reviewed and a copy was issued.