Ivy Park at Palo Alto

ED stated that at a resident town hall, a resident reported that some personal clothing items had gone missing. The facility offered solutions and stated it had policies in place for safeguarding belongings, with staff trained to follow them. ED stated that doors were alarmed and monitored by cameras, and that no unsecured doors had been observed. Residents were permitted to smoke in a designated courtyard area and used their pendants to request reentry. ED further stated that there were two incidents in which unauthorized homeless individuals entered the premises in April and May 2025. Police were contacted in both cases, though no cases were opened. Following these events, the facility reinforced door security, reminded staff of security procedures, and instructed staff to call 911 immediately if unauthorized individuals were observed. S1 stated that S1 was aware of any security concerns at the facility. S1 further stated that while a resident mentioned a missing item in the past, no further issues were reported, and no residents expressed feeling unsafe. S2 stated that S2 recalls two past incidents in which residents mentioned missing personal items, including a ring and money from a wallet. S2 also stated that there had been a few occasions when an unauthorized homeless individual was seen on the property near the trash area before leaving through the back door. S2 further stated S2 was not aware of the individual entering any resident rooms or whether police were contacted. S3 stated that socks of some residents occasionally went missing from the laundry but were later found at the front desk and returned to residents. S3 also stated that an unauthorized homeless individual attempted to enter the facility on several occasions between November 2024 to May 2025, but did not access resident rooms or take anything. Police were contacted during one incident, but the individual was not located. Staff were instructed not to allow the person inside again. S4 stated that a resident had mentioned missing socks but no other belongings. S4 also stated that an unauthorized homeless individual entered the facility a few times between November 2024 and May 2025 through the front door but left without incident. On another occasion, the individual was stopped by the front desk. S4 further stated that side doors were secured with sensors, though the delivery door did not have sensors. R1 stated that cash had been taken from R1’s purse more than two years ago but stated that no cash or belongings had gone missing in the past two years. Continued on LIC9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 R1 reported feeling safe and secure in the facility and described it as a good place to live. R1 further stated that R1 hasn’t seen any homeless person inside the facility. R2 stated that no belongings, cash, or clothing had ever gone missing from R2’s room. R2 stated they had not seen any homeless individuals at the facility, felt secure in R2’s room, and had no concerns about living at the facility. R3 stated that R3’s belongings were safe and had not gone missing. R3 stated that R3 was not aware of other residents reporting missing items and had not seen any unauthorized homeless individuals at the facility. R3 further stated that R3 felt safe living at the facility and had no concerns. R4 stated that none of their belongings had gone missing at the facility. R4 stated that R4 felt safe and secure living there and had no concerns. R4 recalled one incident in which an homeless individual entered the lobby but was promptly escorted out by staff. R5 stated that nothing had ever been stolen from R5’s room and that R5 was not aware of any other residents having items stolen. R5 reported never seeing any homeless individuals at the facility. R5 further stated they felt safe at the facility and had no problems living there. R6 stated that cash had gone missing around the time they moved into the facility and more recently, cash was missing again from their wallet. R6 stated they had kept the cash in the same place since moving in and noticed it was missing when checking their wallet. R6 reported the loss to facility staff, who searched the room but did not locate the money and stated the matter would be reported to the police. R6 stated they had not seen any unfamiliar homeless individuals in the facility and generally felt safe. R7 stated that nothing had gone missing from R7’s room and that only authorized individuals had entered. R7 reported feeling the facility was calm and quiet. R8 stated that laundry items had occasionally gone missing but were always returned. R8 further stated that no cash or personal belongings were missing and that they had not observed any homeless person around the facility. R9 stated that R9 enjoyed living at the facility, received help when needed, and described the food as very good. R9 reported one instance of clothing being mixed up in the laundry but no other missing belongings or cash. Continued on LIC9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 R10’s Primary Emergency Contact (PEC) stated that in April 2025, R10 reported that cash was missing from R10’s bedside table and previously, cash had gone missing as well, though the exact date was not recalled. R10’s PEC stated they were dissatisfied with the facility’s response, which was to advise being more responsible with cash. No police report was filed. R10’s PEC acknowledged that R10 had dementia and may have misplaced the money, but believed the cash had been present before it went missing. On 08/13/2025, LPA obtained and reviewed R1’s Records. R1’s Personal Property and Valuables record showed no items listed. R1’s Medical Assessment report dated 03/21/2025, stated that R1 was able to manage their own cash resources and did not have a dementia diagnosis. R1’s Service Plan dated 09/11/2024, stated R1 was generally oriented to person, time, and place. On 08/21/2025, LPA obtained and reviewed R6’s Records. R6’s Personal Property and Valuables record showed no items listed. R6’s Medical Assessment report dated 07/19/2024, stated that R6 was not able to manage their own cash resources and had a Mild Cognitive Impairment (MCI) diagnosis. R6’s Service Plan dated 03/06/2025 stated R6 doesn’t have cognitive impairment. On 08/21/2025, LPA obtained and reviewed R10’s Records. R10’s Personal Property and Valuables record showed no items listed. R10’s Medical Assessment report dated 02/10/2022, stated that R10 was able to manage their own cash resources and had a Mild Cognitive Impairment (MCI) diagnosis. R10’s Service Plan dated 09/11/202408/01/2025, stated R10 was oriented to person, time, and place. On 08/26/2025, LPA obstained and reviewed the facility's LIC9060 Resident Theft and Loss Record, which listed the missing items and cash for R1, R6, and R7. Based on interviews conducted and records reviewed, although 3 of 10 residents reported incidents of missing clothing or cash, these incidents could not be verified and lacked supporting evidence. All residents confirmed that they had not seen unauthorized homeless individuals inside or near their rooms, and they felt secure living at the facility. Staff acknowledged that homeless individuals had entered the premises on multiple occasions between November 2024 and May 2025, but no evidence indicated that the residents’ belongings were taken by these homeless individuals. The Department has determined that the allegation may have happened or is valid, but there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the allegation(s) are UNSUBSTANTIATED. No deficiencies were cited under the California Code of Regulations, Title 22. An exit interview was conducted with the Executive Director. A copy of this report was provided to the Executive Director, Stephanie Brice, whose signature on this form confirms receipt of the report.

During interview on 07/16/2024, staff S1 stated R1 weighs himself/herself daily and keeps a daily weight log. S1 stated staff check R1’s daily weight log each morning. During interview on 12/05/2024, S1 stated that staff would review R1’s daily weight log, but staff did not record R1’s daily weight in any facility records. During interview on 12/05/2024, S2 stated to have observed R1 experience worsening breathing. S2 stated to have reported S2’s observations about R1’s worsening breathing to S1 and S3, who was the Wellness Nurse at the time. S2 stated to have notified R1’s physician via fax about R1’s worsening breathing. R1’s Progress Notes state that on 01/17/2024, R1 was transferred to the hospital for tremors, difficulty swallowing, and shortness of breath. The Progress Notes state that R1’s doctor and family member were notified. R1’s Progress Notes state that on 06/18/2024, facility staff called 911 to have R1 transported to the hospital for shortness of breath. LPA Marrufo obtained a copy of R1’s Medication Administration Record (MAR) from June and July 2024. The MAR indicates that all centrally stored medications were administered to R1 each day that R1 was at the facility. LPA obtained a copy of a faxed Memorandum from R1’s physician. The Memorandum is dated 07/03/2024. The Memorandum states that staff should assist R1 with administering Medication M1 every day between 8:00 AM to 9:00 AM. The Memorandum also states if R1 weighs more than 183 pounds, staff should assist R1 in administering another dosage of M1. LPA Marrufo obtained a copy of R1’s Administration History of Medication M1, which states R1 received a medication on time every day from 07/06/2024 to 07/15/2024. Page 2 of 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 During interview on 07/16/2024, R1 stated that facility staff provided R1 with only one dosage of M1 per day, but the staff were supposed to provide R1 with two dosages of M1 per day. During interview on 07/16/2024, S1 stated that staff check R1’s weight log each day to determine if R1 will need a second dosage of M1 at 2 PM. Based on information from interviews conducted with staff, and records reviewed, although the allegations listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are unsubstantiated. No Deficiencies were cited under California Code of Regulations Title 22 This report was reviewed with Stephanie Brice, Administrator, and a copy of this report was provided. Page 3 of 3.

An LIC624 Unusual Incident/Injury Report submitted to the Department on 05/26/2023 reports that on 05/21/2023 R1 reported $400 went missing from R1’s apartment. The report states the facility notified the local police department of the missing money. R1’s Progress Note on 06/22/2023 states that R1 informed facility staff that R2’s diamond ring had gone missing. R1’s Progress Note on 06/23/2023 states that facility staff made a police report with the local police department and a police officer visited R1 to investigate the missing ring. During interview, R1 and R2 stated that R1 left $400 of cash in a pouch on a nightstand. R1 stated that R1 later checked the pouch and found the $400 to be missing. R1 stated to have reported the missing money to facility staff. R1 then stated R1’s family member brought a safe deposit box to R1’s room for R1 to store the rest of R1 and R2’s valuables. R1 stated to have waited a week before using the safe deposit box. R1 stated when R1 finally tried to collect R1’s valuables in the safe deposit box, R1 noticed that R2’s ring valued at $50,000 was missing. R1 showed LPA Marrufo the plastic bag that contained the ring box which R1 stated contained the missing ring. R1 opened the ring box for LPA Marrufo and LPA Marrufo observed that the box was empty. During interviews on 07/06/2023, 2 out of 2 family members of R1 and R2 stated to not know what could have happened to the missing money or ring and have no knowledge of where both items could currently be. During interviews, 8 out of 8 interviewed staff stated to have not stolen the money or ring from R1 and R2’s apartment. 8 out of 8 interviewed staff stated to have not observed or heard about money or a ring being stolen from R1 and R2’s apartment. Page 2 of 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 LPA Marrufo obtained copies of R1 and R2’s LIC821 Client/Resident Personal Properties and Valuables forms. Both forms have the word “WAIVED” printed on the first and second pages. Both forms indicate R1 and R2 digitally signed the forms on 01/26/2023. Based on information from interviews conducted with staff, residents, and resident family members, and records reviewed, although the allegation listed above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is unsubstantiated. No Deficiencies were cited under California Code of Regulations Title 22 This report was reviewed with Administrator Stephanie Brice and a copy of the report was provided. Page 3 of 3. END REPORT

Licensing Program Analyst (LPA) Marrufo conducted an unannounced Case Management visit and met with Stephanie Brice, Administrator. LPA Marrufo obtained a copy of the facility California Residential Care Theft & Loss Policy and Procedure document. The documents states on page 1, “2. THEFT & LOSS – The Community shall document the loss or theft of personal property (in accordance with Section 2.A, below) with a then-current value of $25.00 or more within 72 hours of the Community’s discovery of such loss or theft.” The document states on page 2, “7. POSTING – This Policy shall be posted in a location easily visible to the residents of the Community.” The facility submitted an LIC624 Unusual Incident/Injury Report to the Department on 05/26/2023. The report stated that on 05/21/2023, resident R1 reported that $400 was missing from R1’s apartment. LPA Marrufo obtained a Progress Note for resident R1 dated 06/22/2023. The Progress Note stated that resident R1 reported to facility staff that a diamond ring belonging to R1 and R1’s spouse, R2, was missing. During visit on 06/30/2023, LPA reviewed resident and facility records as part of a complaint investigation visit. LPA observed that there was no LIC9060 Theft and Loss Record form completed for the missing $400 and diamond ring that belonged to R1 and R2. During visit on 07/10/2023, LPA interviewed Administrator Kathleen Olson, who stated that there is no Theft and Loss Policy posted in the facility. LPA did not observe a Theft and Loss Policy posted during visit. Deficiencies were made as per California Code of Regulations Title 22. See LIC809-D page for more information. This report was reviewed with Administrator Stephanie Brice and a copy of this report and appeal rights were provided.

On November 15, 2024, Licensing Program Analyst (LPA) Kiran Jain conducted an unannounced case management visit. LPA met with Health Services Director (HSD), Baneen Amiri and Executive Director (ED), Stephenie Brice and explained the purpose of the visit. During the investigation of complaint control number #26-AS-20241024162149, LPA Jain reviewed the facility's incident reports for Resident (R1) and found that the facility did not send any incident reports for R1 to Licensing in which R1 had fall incidents and or was sent to the hospital, from August 31, 2024 to October 17, 2024. Based on the records review done for the facility's internal charting notes records for R1, the following incidents were documented: R1 had fall episodes on 08/31/2024, 10/11/2024, 10/13/2024, and 10/14/2024. The facility observed a bump on R1's right cheek on 10/06/2024. R1 was sent to the hospital on 08/31/2024, 10/11/2024, 10/14/2024, and 10/17/2024. Based on the interview conducted with staff HSD and ED, HSD stated they are not able to keep up and send UIR due to so many fall incidents. Everything related to the falls has been sent and communicated with the family and doctor for any changes from falls, cuts, and increased confusion from R1’s baseline. HSD stated they would send incident reports regarding falls or any other change of condition to the Licensing in the future. Based on record reviewed and interview conducted, the facility did not submit Incident Reports to the Licensing when R1 had multiple fall incidents in the facility and or was sent to the hospital from August 31 to October 17 in 2024 which poses/posed a potential health, safety or personal rights risk to persons in care. A deficiency was cited under the California Code of Regulations, Title 22. Failure to correct the deficiency by the due date may result in civil penalties. See LIC 809-D page for more information. This report was reviewed with Baneen Amiri and Stephenie Brice, and a copy of this report along with appeal rights were provided.

Based on the interview conducted with resident (R1)’s Family Member (FM1) on 10/29/2024, FM1 is aware of R1’s fall history and stated that R1 likes to do things on their own and doesn’t call for help. R1 was getting up and falling without assistance and people around due to medicine drowsiness. R1 had a cut on her backside and a bruise on her cheek. FM1 stated that this particular incident related to bruising was an unwitnessed fall. The facility is not sure how it happened and what caused the bruising. Most probably R1 hit the corner of the bed when they tried to move from the bed to the wheelchair on their own. Probably hit the chair or bed. R1 has Parkinson's dementia. R1 knows they can’t get up on their own. FM1 worked with R1’s doctor to change the medicine so that R1 is not always drowsy. No falls since the change of medicine. FM1 stated they hired a private companion for R1 and adding a private companion helped. FM1 is evaluating if R1 needs a skilled nursing home more than an Assisted Living facility. FM1 stated that the facility is doing a good job taking care of R1, giving medicines, showering, giving meals, and dressing. FM1 have been at the facility when they were working with R1. FM1 has no concerns about the facility, and they got a call every time a fall incident happened, and an EMT was called on all occasions. Based on the interview conducted with staff (S1) on 10/30/2024, S1 stated that R1 moved into the facility about 2 months ago. R1 moved to Assisted Living from rehab with a dog. The facility evaluated and moved R1 from Assisted Living to memory care on the first day only. R1 was constantly tripping over the dog. The dog was handed over to R1’s FM1. S1 stated that R1 is confused, agitated, and suicidal at times, and has a high fall risk. R1 always tries to get out of bed and wheelchair on their own. R1 was in the hospital with bruising. The facility had a care plan around that. R1 is back in the facility from skilled nursing after the last surgery for a fall. The staff brings R1 to the common area of the memory care to do activities and manage and prevent falls/injuries. R1 is angry. R1 doesn’t want to be here. R1 is in her 90s. Bruising is due to the falls. All of R1’s falls are documented/reported on internal charting notes. Staff keep observing R1’s bruising and document its status. S1 stated that R1 has a personal companion from 12-8 PM. This changed her condition. R1 is more clear now. At nighttime, there is no personal companion. However, the facility’s care staff is there during the night shift. R1 has a pendant. R1 is using it. R1 is refusing medication at times. S1 stated that facility staff contacted and worked with R1’s responsible party, doctor, and skilled nursing home to address the injuries from fall incidents and help in managing the falls. Based on the interview conducted with R1’s Personal Companion (PC1) on 11/05/2024, PC1 stated that the facility has been doing well in taking care of R1. R1 has been doing better. Caregivers are always attentive to R1. R1 tries to get out of bed knowing they can't walk and that is the reason they fall. R1 has been active, and the bruising is getting better. R1 has no fall incidents in the past 10 days. Page 2 of 3... Continued on LIC9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Based on charting records review conducted on 11/05/2024, R1 has a high fall risk, is agitated on and off, confused at times, depressed, and verbally stated to kill themselves. On 10/06/2024, R1 was up half the night, agitated, and was throwing things. Medicine was given and was effective. The facility noticed a bump on R1’s right cheek. R1 stated that they tried to pick a fork up and bumped their cheek on the table. Ice pack and pain reliver was given. Family and MD were notified. Staff continued to monitor the bump, R1’s comfort level and continued with the care plan and medications. On 10/14/2024 around 6:20 AM, R1 was found on the floor in half sitting position. R1’s left thigh laceration was noted to be bleeding. 911 was called, the wound was treated, R1 was transferred to the hospital and RP was notified. R1 came back from the hospital on 10/14/2024 at 1:50 PM with a new medication order, had stitches on their laceration, and had 10 stitches on their left outer gluteal. R1 was stable but confused a lot. The facility continued with R1’s care plan, medications, and check on their comfort by monitoring R1. A private companion is with R1 from 12 PM to 8 PM. On 10/17/2024, the facility noted R1’s bleeding at the laceration site with a soiled dressing and sent R1 to ER. R1 came back from the hospital on 10/18/2024 with an updated medication list. No discomfort noted, old bruises on cheek, and forehead are still there. No new falls have been observed since 10/19/2024. On 10/21/2024, R1 was seen by Sutter Home Care, provided wound care, changed dressing, and no infection was noted. On 10/22/2204 R1 had lunch in the dining area. No new bruising was noted. Based on hospital discharge records review conducted on 11/05/2024, R1 has poor safety awareness, is impulsive, has decreased attention/concentration, is disoriented to circumstances and time, and has short-term and long-term memory loss. Medications were updated. The functional assessment mentions that R1 needs assistance in bathing, oral hygiene, and other activities. Based on interviews conducted with the staff, family member, personal companion, and records reviewed, the department has determined that although the allegations listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are UNSUBSTANTIATED. No Deficiencies were cited under the California Code of Regulations Title 22. This report was reviewed with Chris Schuster and a copy of this report was provided. Page 3 of 3. END OF REPORT.

Based on the interviews and records review, when facility staff went to check on R1 in their room, R1 slammed the door at staff, called names, and stated they were there to be independent and wished to be left alone. Staff said to let them know if R1 needs anything. R1 was seen in multiple rooms and locked themselves in the hallway bathroom. S3 attempted to speak to R1 and encouraged them to come out of the bathroom. Staff called 911 to seek help and quickly cleaned R1’s room. R1 continued to order meals delivered to their room for months and didn’t want to come down for meals or attend activities. Per R1, they are not a social person and prefer to stay at their pace. R1 continued to refuse to take certain medications stating I have the right to refuse my medication. S3 tried to explain the side effect of refusing their medication but R1 refused to cooperate. Staff continued to document refused non-administered medications. S3 received a phone call from R1’s doctor to verbally OK to discontinue medication as R1 has the right to refuse. R1 was noted several times to be self-talking and knocking back at the door upon knocking. The facility continued to document, assist, and monitor R1’s changes and continued with the care plan. R1 was observed not to be sleeping well. Stay up the whole night crying, talking, and sometimes screaming. Neighboring residents complained about this behavior. Based on the interviews and records view, S3 and S4 contacted R1’s case worker, VA advocate, PCP, and psychiatrist, the Mobile crisis unit, and the Police department. A police report was obtained by LPA. According to the police report, R1 made it clear that they did not want any service from the police department and slammed the door closed. Based on information from interviews conducted with the staff and records reviewed, the department has determined that although the allegations listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are UNSUBSTANTIATED. No Deficiencies were cited under the California Code of Regulations Title 22. This report was reviewed with Baneen Amiri and a copy of this report was provided.

Based on records review, a police report was obtained by LPA, Staff member (S1) stated that When S1 and S2 went to help R1 get dressed for breakfast, R1 told them he/she didn't want to get up because he/she was sick. S1 then reported to the medical technician. When S1 and S2 went back to assist R1 they attempted to remove the blanket to help R1 get out of bed. When they removed the blanket, S1 observed a bottle of wine on R1's lap. When S1 attempted to grab the wine bottle from R1s lap, R1 became combative and pulled S1s hair. As R1 pulled S1's hair, R1 continuously yelled at them to get out of the room. For R1s statement, on 11-26-23, R1 alleged that caregiver S1 and S2 entered the room and grabbed R1s left forearm and left leg to help R1 get dressed for breakfast. R1 stated he/she did not want to go and told them to leave her alone, but they didn't. When R1 asked S1 to take her to the bathroom, S1 told her “No.'' S1 stormed out of the room and slammed the door on the way out. When R1 was asked if S1 ever struck him/her, R1 stated yes. R1 stated that S1 did not actually strike him/her but was rough and aggressive when trying to get him/her dressed for breakfast. R1 admitted that he/she struck S1 in the chest area when R1 tried dressing him/her because she was squeezing his/her arm tightly. The Administrator (ADM) during this time stated that after these allegations were made, ADM had a nurse at the facility conduct a head-to-toe skin check on R1 the following day (11-27-23). ADM advised that during this physical check, Health Services Director (HSD) did not observe any visible bruising on R1. ADM also stated that RP was not present but stated that one of the caregivers struck R1 in the back and arm, which caused bruising on R1s body. Also in the police report, it was mentioned that from what the Police Officer (PO) observed, R1 did not have any visible injuries when the arm was inspected. The photographs RP took, and it did not appear that R1 was bruised. However, there was slight redness likely to be because of age/sensitive skin. LPA Marrufo was also able to interview staff members. During the interview, S2 was asked if he/she witnessed R1 being hurt by S2 and stated that “No, I didn’t.” S2 did not see personally that S1 hit R1 because S2s back was turned. S2 tried calming R1 down but that is when R1 scratched S2s wrist. R1 was very anxious and aggressive. S2 also did not observed any injuries on R1s forearm. Based on interviews & records review, the department has determined that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Report is reviewed and copy is 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 However, due to the incidents that R1 was refusing care and assistance from the staff, they were only able to dress R1. Also based on the police report, R1 continuously yelled at the staff to get out. While there may be staffing issues during this day, the Facility was already allocating staff to assist other residents. LPA Marrufo was able to interview another staff member (S3), and it was mentioned that the family member (F1) came the moment S3 was with R1. F1 asked S3 what happened and S3 said “I didn’t know.” F1 told S3 that he/she would lower R1 down to the dining room for breakfast. It was in the morning. S3 normally lower the resident’s downstairs to the dining room for breakfast. F1 said don’t worry, and that F1 will take R1 to breakfast. Based on interviews and observations, the department has determined that that the allegation was false, could not have happened and/or is without a reasonable basis, therefore the allegations are UNFOUNDED. Report is reviewed and copy is provided.

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Andrew Pence. The purpose of the visit was to address additional reports that were brought up as part of a previous complaint investigation. On 10/19/2023, LPA Marrufo interviewed resident R1's Responsible Party, who stated to have observed R1 have a fall in the shower while being assisted by a staff. R1's Responsible Party stated the fall occurred sometime around 3-5 months ago. R1's Responsible Party stated R1 was holding on to the grab bar in the shower when R1 began to lose balance and slid down to the shower floor. R1's Responsible Party stated to have asked the staff if the staff was going to report the fall, and the staff stated stated he/she would report the fall. R1's Responsible Party did not know the name of the staff who assisted R1 in the shower and witnessed R1's fall. R1's Responsible Party also reported to have spoken to another staff who was a medication manager on the memory care floor of the facility and reported the fall to the medication manager. R1's Responsible Party could not recall the name of the medication manager to whom R1's Responsible Party reported R1's fall. During visit, LPA Marrufo interviewed staff S1-S5 and resident R1. Staff S1-S5 stated to have not observed any incidents in which R1 fell in the shower. S1-S5 stated that a resident falling in the shower, including if the resident slides to the floor after losing balance, should be reported. Review of resident records indicate that there is no record of the witnessed fall that R1 had in the shower. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Andrew Pence and a copy of the report and a copy of the report was provided.

Staff S2-S11 and Residents R2-R6 stated during interview to have never observed alcohol in the facility besides in the kitchen area, to have never observed a staff consume alcohol at the facility, and to have never observed a staff appear to be under the influence of alcohol at the facility. LPA Marrufo interviewed resident R1 who stated to have never had a resident drop R1 during a transfer. LPA Marrufo obtained a copy of R1's Appraisal/Needs and Services Plan, which states R1 needs transfer assistance from 1 staff. Based on information from interviews conducted with staff and residents, observations, and records reviewed, although the allegations listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are unsubstantiated. No Deficiencies cited under California Code of Regulations Title 22. This report was reviewed with Andrew Pence and a copy of this report was provided.

R1’s Visual/Bedside Individual Service Plan Report is dated 03/29/2021. The Dressing section states “Stockings: Compression applied – REMIND HIM to apply” and “Stockings: Compression removed – REMIND HIM to remove.” R1’s Physician made an order to the facility for R1 to have compression stockings for both feet on 01/27/2021. R1’s Intervention Schedule indicates that the first entry for reminding R1 to apply and remove R1’s compression stockings started on 01/27/2021. The Intervention Schedule has an “X” on the following days for the intervention of staff reminding R1 to remove the compression stocking: 01/31/2021, 02/28/2021, and 03/31/2021. The rest of the days of the month from January to March 2021 indicate that staff reminded R1 to apply and remove R1’s compression stocking. During interview, staff S1 stated that an “X” may indicate that either staff missed the intervention, or the resident refused the intervention. Witness 1 (W1) provided photographs to LPA Marrufo of what W1 says is R1’s ankle showing markings of the fastener from the compression stockings. R1’s ankle appears narrower where the fastener markings are visible. LPA Marrufo reviewed R1’s resident record and did not find any document from R1's physician holding facility staff responsible for assisting R1 with the use of the compression stockings. R1’s resident record contains a note from R1’s Primary Care Physician (PCP) from 08/16/2021 stating that R1 is refusing to apply the compression stocking. Page 2 of 8. 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 Marrufo interviewed 8 residents, 3 resident responsible parties (for 3 out of the 8 interviewed residents who were from memory care), and 10 care giver staff, and 3 kitchen staff. During interview, resident R1 stated that the facility staff follow R1’s physician’s orders. 6 out of 8 interviewed residents stated the facility staff follow their physician’s orders. 1 interviewed resident did not respond to LPA’s questions. 1 out of 3 interviewed responsible party refused to be interviewed. 2 out of 3 interviewed responsible parties stated facility staff follow physician’s orders. 9 out of 10 interviewed facility staff stated staff follow resident’s physician’s orders. 1 out of 10 interviewed staff stated staff do not follow R2’s physician’s orders for R2’s compression stockings. LPA Marrufo reviewed R2’s Intervention Logs for January through March 2021. The Intervention Logs indicate that staff assisted with R2’s compression stocking each day of the month from January through March 2021. Staff S1 stated R2 is deceased and is no longer at the facility. The Medication Technician (Med Tech) Schedule for January through March 2021 indicates that in Assisted Living there is a Med Tech scheduled in the AM shift and another in the PM shift; in Memory Care, there is a Med Tech scheduled in the AM shift and another in the PM shift each day of the month. The Staff Schedule for January through March 2021 indicates there are between 12-14 staff scheduled each day of the month. R1 stated during interview that staff meet the supervision needs of the residents. 6 out of 8 interviewed residents stated the staff meet the supervision needs of the residents. 1 out of 8 interviewed residents did not respond to LPA’s questions during interview. 1 out of 3 interviewed reporting parties refused to be interviewed. 2 out of 3 interviewed reporting parties stated the staff meet the supervision needs of the residents. Page 3 of 8. 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 10 out of 10 interviewed staff stated the staff meet the supervision needs of residents. R1’s Intervention Log from January through March 2021 indicates all interventions are recorded as completed each day except for the dinner meal on the last day of each month. R2-R4’s Intervention Logs from January through March 2021 indicate all interventions are recorded as completed each day except for the dinner meal on the last day of each month. R1 stated during interview that staff assist residents with activities of daily living. 5 out of 8 residents stated staff assist residents with activities of daily living. 1 out of 8 residents stated to not know if staff assist residents with activities of daily living. 1 out of 8 residents did not respond to LPA’s questions. 1 out of 3 interviewed responsible parties refused to be interviewed. 2 out of 3 interviewed responsible parties stated staff assist residents with activities of daily living. 10 out of 10 interviewed staff stated staff assist residents with activities of daily living. R1’s resident record contains an Introductory Letter from a podiatrist (Pod1) and a notice signed by R1’s responsible person stating that podiatry services will not be covered by R1’s insurance policy. A facility Notice dated 02/24/2021 states that the beautician will resume service at the facility for both assisted living and memory care residents and will follow COVID protocols, including wearing a face shield and double masks. The Notice states the beauty salon services will be by appointment only and provides a telephone number to schedule an appointment. Page 4 of 8. 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 Podiatry Schedules for November 2020 through February 2021 (LPA did not obtain a copy of the January 2021 Podiatry Schedule) each have the word “postponed” written on them. R1 is listed on the roster of residents who had podiatry visits scheduled each month. The Podiatry Schedule from March 2021 includes R1 on the roster of residents with scheduled podiatry visits. R1 stated during interview that staff assist residents with basic services. 5 out of 8 residents stated staff assist residents with basic services. 1 out of 8 residents stated to not know if staff assist residents with basic services. 1 out of 8 residents did not respond to LPA’s questions. 1 out of 3 interviewed responsible parties refused to be interviewed. 2 out of 3 interviewed responsible parties stated staff assist residents with basic services. 9 out of 10 interviewed staff stated staff assist residents with basic services. 1 out of 10 interviewed staff stated staff do not assist residents with basic services. R1’s Physician’s Report states R1 is able to feed self. R1’s Visual/Bedside Individual Service Plan Report states R1’s meals will be prepared by the facility and R1 prefers full portions to meals. The report states R1 is independent with dinning and should be observed for any changes in R1’s level of independence with dinning. R1-R4’s Intervention Logs from January through March 2021 indicate staff assisted the residents with meals for every meal except for dinner on the last day of each month. The Production Summary Worksheet with Temperatures Log records cooking temperatures of at least 140 F and up to 160 F for all cooked foods from November 2020 through March 2021. Page 5 of 8. 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 facility Menu for December 2020 through January 2021 indicate that breakfast, lunch, and dinner meals are served each day. Breakfast meals offer choices of eggs. Lunch and dinner meals offer salads, soups, a main course, sandwiches, and dessert options. Witness 1 (W1) provided photographs to LPA Marrufo of a bowl with leafy greens, a disposable tray with an enchilada and refried beans, and another disposable tray with corn and sauced meat meal. R1 stated during interview that staff provide meals of quality and quantity to meet the needs of the residents. 5 out of 8 residents stated staff provide meals of quality and quantity to meet the needs of the residents. 1 out of 8 residents stated to not know if staff provide meals of quality and quantity to meet the needs of the residents. 1 out of 8 residents did not respond to LPA’s questions. 1 out of 3 interviewed responsible parties refused to be interviewed. 2 out of 3 interviewed responsible parties stated staff provide meals of quality and quantity to meet the needs of the residents. 10 out of 10 interviewed staff stated staff provide meals of quality and quantity to meet the needs of the residents. LPA Marrufo interviewed 3 kitchen staff. 3 out of 3 kitchen staff stated the facility serves warm meals to residents, the meals are served with portions of a sufficient size for the residents, and residents can ask for seconds, including if the residents are in their living units. LPA Marrufo observed the heater coils used to keep food warm in the kitchen and the heater carts used to transport the meals to the residents while maintaining the meals at a warm temperature. LPA Marrufo observed there to be a microwave in the kitchen, which 3 out of 3 interviewed kitchen staff stated is used to reheat the meals if the meals have become cold. Page 6 of 8. 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 R1’s Physician’s Report states R1 is able to take care of R1’s own toileting needs. R1’s Visual/Bedside Individual Service Plan Report states R1 is independent with assistance to the bathroom and is continent of bladder and bowel. R1’s Intervention Log for January through March 2021 states staff assisted R1 with all care interventions for Bladder Continence, Bowel Continence, Grooming, Assistance to Bathroom, and Laundry. R2-R4 Intervention Logs for January through March 2021 states staff assisted each resident with all care interventions for Bladder Continence, Bowel Continence, Grooming, Assistance to Bathroom, and Laundry. R1 stated during interview that staff accord the residents with dignity. 5 out of 8 residents stated staff accord the residents with dignity. 2 out of 8 residents did not respond to LPA’s questions. 1 out of 3 interviewed responsible parties refused to be interview

An assessment was done and no apparent injury was noted. R1 denied any pain or discomfort. Staff notified R1’s spouse and R1’s Primary Care Physician (PCP) visited R1 at 10:00 AM. PCP noted R1 was able to move all extremities at baseline and R1 continues to deny pain or discomfort. The Transfer/Discharge Report dated 04/23/2020 states that R1’s diagnoses include fracture of lower end of right fibula and muscle weakening and atrophy on multiple sites. R1’s Appraisal/Needs and Services Plan states that R1 needs two staff to assist R1 with transferring. This assessment was completed on 05/05/2018. During interview, R1 stated that two staff assisted R1 during transfer on 03/22/2020. R1 stated to not remember who the two staff were. R1 stated to have confidence in the abilities of facility staff. During interview, staff S1 stated to not be able to recall who were the two staff who assisted R1’s transfer on 03/22/2020. S1 is the staff who wrote the Incident Report. R1’s Physician’s Report states R1 is not able to care for R1’s own toileting needs. R1’s Appraisal/Needs and Services Plan states R1 needs to be provided with frequent assistance to change R1’s incontinent product. R1’s Progress Notes from 02/13/2020 notes R1 continues to wear condom catheter and a new bag was put in place. In-service done with care team for proper instructions. The facility Training Participation Log states on 03/18/2020, a training on Condom Catheter and Urostomy was provided to staff. See LIC9099-C for more information. Page 2 of 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 R1’s Intervention Logs for January, February and March 2020 include “Remove catheter at daytime” and “Bladder Continence” as interventions. Each intervention has an entry specifying the intervention was completed for each required instance. During interview, R1 stated to not recall how staff emptied out R1’s catheter. R1 stated to not recall if there were any times the staff emptied the catheter on the carpet or if R1’s apartment had an odor of urine. R1 stated R1 would “probably remember something like that because it is gross.” R1 stated to remember urinating into a container and the container never leaked. LPA did not observe an odor of urine in R1’s living unit during visit. Staff S1 stated to have never observed any times R1’s living unit smelled like urine. S1 stated to have never had any concerns of staff emptying R1’s catheter on the carpet or floor. Based on information from interviews conducted with staff and resident, and records reviewed, although the allegations listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are unsubstantiated. No Deficiencies cited under California Code of Regulations Title 22 This report was reviewed with Fatima Vicente-Dimanlig and a copy of the report was provided. Page 3 of 3. END REPORT. 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 R1’s updated Appraisal/Needs and Services Plan states R1’s move in date is 04/29/2020. This agency has investigated the complaint allegations listed. Based on interviews, review of records, and observations, the CCLD has found that the complaint allegation is unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. This report was reviewed with Fatima Vicente-Dimanlig and a copy of the report was provided. Page 2 of 2. END REPORT

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Administrator Grace Komasaka. LPA Marrufo toured the inside and outside of the facility. LPA Marrufo observed there to be a a visitor screening area at the entrance. LPA Marrufo observed there to be a PPE supply of at least 30 days, a perishable food supply of at least 3 days and a non-perishable food supply of at least 7 days. LPA Marrufo observed the facility bathrooms to have available soap and paper towels as well as COVID-19 hand washing posters. LPA Marrufo toured the outside area and found the exits to be cleared of obstructions. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Administrator Grace Komasaka and a copy of the report was provided.

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required - 1 Year visit and met with Grace Komasaka. During visit, LPA Marrufo toured the facility. LPA Marrufo observed the visitor screening area. LPA Marrufo toured 3 out of 3 hallway bathrooms and found them to have available soap and paper towels. LPA observed facility staff break rooms and observed there to be COVID-19 related posters posted on the walls. LPA observed the facility PPE supply room and observed there to be a 30-day supply of PPEs. LPA observed the facility dining area and the facility hallways, visitor area, and memory support floor. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Grace Komasaka and a copy of the report was provided.