Astoria Park Senior Living.

information gathered it was revealed by Resident's R2-R11 that staff are very kind and helpful. All stated that staff treats everyone with respect and dignity and have never mocked or laughed at any resident. All said staff are very polite and terrific. Resident R8 said that she admires whomever is training staff. Administrator stated that staff would cater to Resident R1 and even give clothes because R1 didn't have alot. Staff S3 said they treated R1 kindly and R1 would say she loves staff and they are angels. Staff S1-S4 all stated that staff treat all residents with respect and dignity. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. In regards to the allegation Personal accommodation in bedroom is inadequate, based on interviews conducted and information gathered Administrator stated that the family tours the bedrooms and they pick and choose the room. It is approved living space by the family and R1 is part of the ALW program in which R1 has a shared room. Residence and Care Agreement was signed by Authorized Representative of R1 on 2/12/2025. Interviews with R2-R11 who all stated that their rooms were spacious and clean. Said housekeeping comes there 1x a week. All stated that the room is still sufficient for those who have wheelchairs or walkers. Staff S1-S4 all stated the rooms were spacious and sufficient. Staff S3 stated that she worked on the admission of R1 and said they work with the ALW Program. Stated that during the assessment they will tell them they will have a roommate. Said they were taken on a tour and shown a room with 2 residents so they will know exactly what they will have. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. In regards to the allegation Staff did not assist with resident's needs, based on interviews conducted and information gathered Resident's R2-R11 all stated that they get their care needs met. All stated that staff respond promptly when residents ask for help. R2 stated he used the clicker for assistance and staff came within 1 minute.Administrator stated that if a resident requested physical therapy it has to go thru the doctor first. It's applied for because with medical they have to wait for approval. 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 Staff S1 stated that R1 was always showered and was very verbal and would let staff know if she needed assistance.Staff S3 said that staff were always friendly with R1 and that R1 loved staff and called them angels. Stated they took very good care of R1 and they knew R1's daily schedule of what R1 needed and were very on top of what was needed for R1. Staff S4 stated that she helped assist R1 with showering and changing clothes and getting dressed. Said staff would bring R1 clothes because R1 didn't have alot. Stated that she knows her schedule and when R1 wants certain things to be done. Said R1 was very nice and polite. It should be noted that R1's last day residing at the facility was 5/2/2026 Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and copy provided to Administrator.

Regarding the allegation: Staff left a resident in a soiled diaper for a long period of time. It is alleged that staff are not changing R1’s and R2’s adult briefs for long periods of time during the NOC shift. It is alleged staff takes very long time before responding to residents’ incontinent needs. Eight (8) of Eight (8) staff deny this, according to staff residents are check for incontinent changes upon starting, during and before the end of each shift, staff stated providing Assisted daily Living needs to residents needing incontinent services three times per shift and as needed for a few residents requiring constant incontinent care needs. During NOC shift staff make nighty checks upon incontinent needing residents, staff periodically checks upon residents' needing constant incontinent care due to their medical conditions and avoid residents' developing UTI's and sores on their privates. Staff stated they communicate residents’ issues with the next shift and take appropriate actions when required. Nine (9) of eleven (11) residents could not corroborate this allegation. Residents stated they receive incontinent care throughout the day and night and when needed. Residents' also stated, not being left in soiled adult briefs to develop a sore in their private areas. Six of eleven residents stated staff responds within 10 minutes of call for incontinent care. Based on interviews and records review, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Regarding the allegation: Staff did not administer medications to a resident in care. It is alleged that staff are not administering medications to R1. Eight of eight staff deny this, staff stated administering R1’s medications as prescribed by the physicians’ orders. Medication is administered one hour before or after the medication stated times. Review of medical records for R1 observed medications administered and refused by R1, PRN medication for pain did not exceed prescribed amount. Seven of eleven residents stated being administered their medications within a reasonable time. Based on interviews and records review, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Exit interview was conducted and a copy of this licensing report was provided to Executive Director, Maria Quizon.

It revealed that staff and med tech would not administer insulin to residents and facility policy did not allow staff to administer insulin to residents since staff were not medical professional. Per observation during medication time, med techs only assisted residents to set up and prepare the medication/insulin. All residents administered insulin by themselves. Therefore, it was not observed that insulin was administered by staff at the facility. Based on the information obtained during the investigation, interviews with staff, residents, review of resident files and LPA's observation, the investigation did not reveal any evidence to support the allegation mentioned above. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegations are UNSUBSTANTIATED. An exit interview was conducted with Maria Teresita Capito Quizon, administrator. The findings were discussed and a copy this report was provided.

Ten (10) out of eleven (11) residents interviewed could not corroborate the allegation. It revealed residents were treated with respect and dignity. Per staff interviews, all six (6) out of six (6) staff interviewed could not corroborate the allegation which indicated staff would treat residents with respect and dignity. During the facility tour, LPA observed residents were looking happy when talking to staff. Staff would say hello to residents and have short conversations with them. Therefore, residents are treated with dignity and respect. In regards of facility staff did not provide adequate laundry services to resident, it was alleged that laundry service was not provided regularly and clean clothes were not hung in the closet but folded in resident’s bed. LPA interviewed residents, one (1) out of eleven (11) residents interviewed stated that laundry staff did not wash the resident’s clothes once a week and resident had to remind staff to provide laundry services. Ten (10) out of eleven (11) residents interviewed could not corroborate the allegation. It revealed that laundry services were provided at least once weekly and more if needed. Their clothes were hung in the closets. Per staff interviews, all staff interviewed could not corroborate the allegation which indicated laundry services were provided at least once every week and more if requested. Staff would check on residents when called for laundry services. During the physical plant, all residents’ clothes were observed to be hanging in closets and no clothes were laid in bed. Thus, staff provided adequate laundry services to residents. In regards of facility staff did not safeguard resident's personal belongings, it was alleged that some hangers and money were missing in resident#1 (R1)’s room while in care. LPA interviewed residents, one (1) out of eleven (11) residents interviewed stated that some hangers were missing in the closet and some clothes were taken by the roommate, but the resident was unable to confirm money was missing in the room. During the resident interview, LPA visited R1’s room to interview R1’s roommate, resident#2 (R2). R2 was non-ambulatory and needed assistance to get up/out of bed. R2 also needed assistance to transfer to wheelchair and dressing/grooming. Ten (10) out of eleven (11) residents interviewed could not corroborate the allegation. It revealed that residents were not aware of any missing hangers or personal belongings while in care. Per staff interviews, all staff interviewed could not corroborate the allegation which staff would assist residents to locate the missing personal belongings when reported missing. The facility has extra hangers in the storage and would provide resident with more hangers if requested. As a result, staff did not fail to safeguard resident’s personal belongings. (-continued on LIC 9099C-) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 In regards of facility staff did not adequately address a change in resident’s condition, it was alleged that resident was noted with increased confusion and staff did not address it properly. LPA interviewed residents, one (1) out of eleven (11) residents interviewed stated that staff did not report resident’s change in condition correctly and the resident insisted that was not change in resident’s mental status. Ten (10) out of eleven (11) residents interviewed could not corroborate the allegation. It revealed that staff would address residents’ changes in condition and notify their families / primary physicians. Per staff interviews, all staff interviewed could not corroborate the allegation which staff would document residents’ changes, notify administrator and report the changes to residents’ primary doctors. Per record review, in-service training was provided to staff related to changes in conditions. Besides, records showed med tech and care coordinator had observed resident's changes. The changes were documented in resident's notes on 01/11/26, 01/16/26, 01/21/26 and 01/28/26. Psych counsel was provided to resident on 02/10/26. Physician assistant visited and evaluated the resident on 02/12/26. Resident's prescription was updated on 02/12/26 today. Additional lab tests and assessments were requested. Therefore, staff had adequately addressed residents’ changes in condition. Based on the information obtained during the investigation, interviews with staff, residents, review of resident files and LPA's observation, the investigation did not reveal any evidence to support the allegations mentioned above. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegations are UNSUBSTANTIATED. An exit interview was conducted with Maria Teresita Capito Quizon, administrator. The findings were discussed and a copy this report was provided.

Regarding the allegation " Staff did not ensure residents personal property was safely secured ”: it was reported that R1 stated that they had money stolen. The investigation revealed 5 out of 5 staff deny the allegation. S1 stated nothing had been reported to them, especially not money. S2 stated an incident was brought to their attention and attempted to assist R1 in looking for the missing money but R1 stated they were not missing anything. Interviews with residents revealed 7 out of 10 residents deny the allegation. R1 stated they had reported someone had taken their money, but they were mistaken because they had somebody to hold it. R2 stated once, about 10 years ago, money went missing from their room, but not now under the new management. R3 stated cigarettes had gone missing from their room but not any money. R4 stated a sweater set was not returned from laundry but has not had money missing. R3 and R4 admitted to not reporting the missing items to staff. LPA unable to interview the reporting party. LPA made three (3) attempts to contact the reporting party. Based on interviews, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided to Administrator Maria Quizon.

The investigation revealed the following: In regards to the allegation: "Staff are not allowing resident to leave facility ." It is alleged that staff did not allow R2 to leave the facility with R1 and staff did not treat them with dignity, comparing the environment to being incarcerated in a state penitentiary. Staff interviewed denied the allegation. Staff stated that they are trained on resident rights and residents are allowed to leave the facility if they choose to. However, some residents, including R2, have restrictions based on doctor's orders and are required to have permission from a family member to leave unassisted. Staff stated that based on the documented care plans that were required for R2's care and due to safety concerns, R2 was not permitted to leave the facility unassisted. Additionally, there was an instruction requiring that a family member (FM) grant authorization before R2 was permitted to leave the community. Staff confirmed that no residents are restrained and that R2 does not have a restraint device. (11) out of (15) residents interviewed stated that they can leave the community whenever they want and none of the staff ever tried to stop them. (3) out of (15) stated that they wanted to leave the facility on their own but their doctor restricted them to leave unassisted. Some interviewed residents also stated that they feel safe leaving and have not been threatened by any staff when leaving the premises. Review of R2's Physician's report indicated that R2 cannot leave unassisted. LPA also confirmed the family member's instruction about getting permission for R2 to leave the community. During the visit, LPA also observed that the reception area maintains a list of residents who are restricted to leave the facility unassisted. Furthermore, the facility maintains a sign in and out logs and residents are free to come and go. Therefore there was insufficient evidence to corroborate with this allegation. Based on statements and interviews conducted with residents and staff as well as reviewed files and documentation, there was not enough supportive evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided to Maria Quizon, Executive Director.

Regarding allegation: Staff provided unwashed utensils to resident in care. It is alleged that the staff does not follow proper cleaning procedures for utensils used by resident in the dining room area. Investigation consisted of interview with staff, residents, and LPA observations. LPA interview with residents revealed that ten (10) out eleven (11) residents denied the allegation above. Residents stated that residents have not seen or heard of utensils to be dirty or unwashed. Residents stated that facility is clean and staff do a great job. Residents stated that staff wraps utensils in napkins to keep them clean. LPA interview with staff revealed that seven (7) out of seven (7) staff denied the allegation above. Staff stated that staff has not heard of any issues with dishwasher that would fail to clean utensils or dishes. Staff stated that sometimes residents use utensils and place utensils back on the table, but if staff notices it, the staff will remove utensils or dishes that have been used by residents. LPA observed the dish washing station while washing breakfast utensils and dishes. LPA did not observe staff failing to follow cleaning procedure for utensils and dishes. LPA observed serving stations and all utensils and dishes were clean. Based upon the investigation, residents and staff interviews, and LPA observations, there is no evidence to support that the facility staff is failing to wash utensils and dishes. Regarding allegation: Staff did not attend to resident call for assistance. It is alleged that R1 has fallen a couple of times and staff failed to provide assistance. Investigation consisted of interview with staff, residents, and LPA observations. The investigation reveals the following: LPA interview with residents revealed that six (6) out eleven (11) residents denied the allegation above and stated that staff have responded in a timely manner or that residents have not needed to call for assistance. R8 stated that R8 used the call pendant, and the staff response was quick. Residents have observed that staff take longer to respond in the morning when staff prepares residents for grooming, showering, and escorting residents to the dining area. Eight (8) out eleven (11) residents stated that staff treats residents well and with respect. Interviews with staff reveal that seven (7) out of seven (7) staff denied the allegation. Staff denied not responding to residents call for assistance. Staff stated that the average response time is 10-15 minutes. If a caregiver is not able to respond, the med tech team assist with residents calls for assistance. Staff stated that the morning shift is more challenging for the number of residents who request assistance for preparing residents for breakfast, showering, and grooming. LPA tested the call system on four residents rooms. LPA observed that staff responded within the average response time in three (3) out of four (4) calls for assistance. Based upon the investigation, residents and staff interviews, and LPA observations, there is no evidence to support that the facility staff is not attending residents call for assistance. Report continues on page 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 Regarding allegation: Staff did not keep the facility free of pests. It is alleged that the facility does not maintain facility clean free of bugs such as fleas. Investigation consisted of interview with staff, residents, facility work order logs for the period of 04/6/2025 thru 07/01/2025, Pest control invoices, and LPA observations. The investigation reveals the following: The facility work order logs records four instances, in three different residents’ room, where residents requested for bug spray in their rooms for flies. Pest control invoices revealed that the pest control treatments are done once a month. LPA interview with residents revealed that eight (8) out eleven (11) residents denied the allegation above and stated that they have not seen or heard of any pest in residents’ rooms including roaches, fleas, or flies. R1 and R5 stated that residents had seen gnats come in through the window, but if reported, staff will spray quickly. Interviews with staff reveal that seven (7) out of seven (7) staff denied the allegation. Staff denied knowing that the facility has issues with pest. Staff described issues with flies in rooms due to residents bringing fruit to residents’ rooms. Staff described water bug or roaches in patio drains but pest control is immediately contacted to treat the area. Staff denied hearing any issues with fleas. LPA did not observe any pests in residents rooms and common areas in the facility. Based upon the investigation, residents and staff interviews, document reviews, and LPA observations, there is no evidence to support that the facility staff is not maintaining the facility free of pests. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview held with Executive Director Maria Quizon. A copy of the report was provided.

Regarding Allegation: Staff did not ensure residents personal property was safely secured. It was alleged that R1's personal belongings stolen. Interviewed Administrator and staff denied the allegation. They stated that all residents personal belongings are safety secure. They indicated that they have never stolen any resident personal belongings, never heard of any residents stealing anyone's personal belongings, and would notify and report it if they did hear of them stealing. They stated sometimes residents’ personal belongings were misplaced in their rooms or being stored in their closets after washed, but never stolen. Interviewed Administrator stated that if there is any report from the residents regarding any missing personal belongings they will talk to the staff immediately to assist the residents to find the item. Administrator stated that they will check the room, laundry, common areas. Interviewed Administrator and staff stated that they didn't hear from the residents that their personal items were stolen. All interviewed residents stated none of their personal belongings have gone missing. They stated they haven't heard of any one stealing someone's personal belongings. Review of R1's file Client/Resident Personal Property and Valuables document dated 2/11/25, has signature of R1's representative which states: "At the present time I decline to track personal property". Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated. Exit interview was conducted and the copy of this report was provided.

(Continued from 9099) Facility staff were unable to identify the resident or person setting the alarm. The Executive Director stated that she will be having refresher training for staff to be able to monitor the residents to prevent this from happening again. She also stated that she will hold a meeting with the residents to answer any questions they may have. The person responsible for setting off the fire alarm has not been identified, and facility is addressing the issue. Executive Director stated she will install covers for the alarms in assisted living like they have in memory care to address the issue. There is insufficient evidence to substantiate this allegation. Based on interviews conducted, there is insufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted, technical advisory issued and a copy of this report was provided along with appeal rights.

In regard to the allegation “Staff do not safeguard resident's personal belongings”, it is alleged that R1 was missing prescription glasses. During interviews with Administrator and staff four (4) out of seven (7) stated that R1 always takes off his/her glasses and puts them down. Staff stated that R1 needs to be remined to put on their glasses and they are always found under the bed or in the pillows. Administrator stated that although R1 may have never took of glasses before this could be a new behavior with someone with dementia. During interviews with residents two (2) out of five (5) residents stated they have never had anything missing from facility. R3 stated that they had a missing item but never reported it to staff. In regard to the allegation “Staff do not respond to calls from resident's representative in a timely Manner”, it is alleged that facility took to long to respond to phone calls and emails about R1’s missing item. During interviews with Administrator and staff seven (7) out of seven (7) stated that they always call back family and friends in a timely manner. Administrator stated that it took three days to call representative of R1 back because that was their first day working at the facility. S4 stated that he/she took the call from the representative on Saturday and informed them that the people they were emailing were no longer with the company. S4 all stated that they personally went to look for the missing item. LPA interviewed three (3) witnesses by telephone and all three stated they have had no issues in regard to callbacks or emails from the facility. Witness #2 two stated that it might take a little longer for a caregiver to call back but that’s because they are busy with residents. LPA obtained emails from S4 to staff explaining glasses were missing and new email contacts were proved to R1’s representative. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was provided. _

Allegation: Staff does not ensure facility plumbing is in good repair. It has been alleged that last Summer (2) hallway bathrooms were out of order for over a month and that this facility lacks proper maintenance, upkeep and does not repair bathroom plumbing in a timely manner. Staff interviews revealed that all hallway bathrooms have been and continue to be operational (including Summer 2025). Interviewed staff indicated that this facility has not had any major plumbing problems. Interviewed staff indicated that the most common plumbing issue is clogged toilets (due to wipes being flushed down the toilet which causes the toilet to be clogged). Per staff interviews, when toilets get clogged, the maintenance staff repair the issue in a timely manner (same day). Staff indicated that they have not received complaints/concerns pertaining to plumbing repairs not being completed in a timely manner. Resident interviews revealed that they do not have any concerns pertaining to the plumbing at this facility. Interviewed residents indicated that they have not had any plumbing issues in their bathrooms nor there has been any issues in the common area bathrooms. Interviewed residents did not have any concerns pertaining to this matter. LPA conducted a tour of the following and did not observe any plumbing issues: restroom near the employee lounge (1 st floor), bathroom near the discovery room (1 st floor), restroom near room #254 (2 nd floor), restroom near the activity room (2 nd floor), room #107, room #111, room #113, room #114, room #115, room #213, room #250, room #224 and room #260. Interviews and tour do not corroborate this allegation. Allegation: Staff do not treat residents with respect. It has been alleged that staff come across “as rude and arrogant and unfriendly” and that staff are “gossiping and spreading immature rumors that are untrue of residents”. Staff interviews revealed that staff are not rude, arrogant nor unfriendly. Interviewed staff indicated that they do not gossip and/or spread any rumors nor have they witnessed any staff doing this. Interviewed staff indicated that they are trained in Resident Rights and Mandated Reporting. Interviewed staff indicated that they have not received any complaints pertaining to this matter. Interviewed residents indicated that staff are respectful, helpful and courteous. Interviewed residents have not heard nor witnessed any staff being disrespectful to anyone. Interviewed residents have not heard anyone complaining about this matter. Interviewed residents indicated they do not have any concerns. Interviews do not corroborate this allegation. Although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report and appeal were provided to Maria Quizon.

The investigation revealed the following: Allegation: Staff did not keep facility free of insects. It is alleged that the facility has a roach infestation. LPA toured facility, the kitchen/dining, 1 st floor and 2 nd floor, and a total of 8 resident rooms were inspected and LPA did not observe any insects or roaches throughout the facility. LPA interviewed 6 staff and each denied the allegation, interview with S1 revealed that there is a monthly pest control that inspects and services the facility and there have been no observations of any insects or bugs at the facility. LPA interviewed 11 residents and 9 out of 11 residents denied the allegation and stated that they have not observed roaches anywhere in the facility or their rooms. Allegation: Staff overcharged a resident in care. It is alleged that R1 was accused of not paying rent and forced to pay their rent twice to avoid eviction. LPA reviewed R1’s file and observed that R1 is set up on an auto withdrawal and month of July 2025 was skipped but paid in August 2025, therefore, the month of August had 2 charges. LPA interviewed 6 staff and each denied the allegation, interview with S1 revealed that there was an error in the month of July 2025 where several residents including R1 did not get charged, during an audit in August the error was discovered and residents were informed and each (including R1) agreed to pay in the month of August. S1 stated since that error was found their procedure for auto payments have changed to where now instead of staff manually inputting the information to authorize the withdrawal each month, those on auto pay are now electronically on a payment plan where funds will be withdrawn automatically with no need of staff manually processing payments. LPA interviewed 11 residents and 10 of the 11 residents denied the allegation and stated that they have not had any issues with their rent and have never been over charged. Allegation: Staff did not seek timely medical attention for resident in care. It is alleged that R1 experienced a fall last summer and had to wait hours for medical transport. LPA reviewed R1’s file and did not observe any notes indicating R1 had a fall and file revealed that R1 is independent and fully ambulatory. LPA interviewed 6 staff and each denied the allegation and stated that staff tend to residents immediately, if staff are busy assisting another resident when a call is heard another available staff will assist or that staff will assist as soon as they are done with the resident they are working with. LPA interviewed 11 residents and 10 out of 11 residents denied the allegation and stated that they have never had any issues with getting medical attention in a timely manner. (Continued on the LIC9099-C 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 Allegation: Staff refused to assist resident in care with their insurance application. It is alleged that S1 refused to assist R1 with getting their insurance set up. LPA reviewed R1’s file and observed that they have valid insurance, resident is self responsible and schedules their own visits. LPA interviewed 6 staff and each denied the above allegation, interviews with S1, S2 and S4 revealed that upon admission the insurance is set up and residents are assisted with being added to an assisted living waiver program that provides assistance/supplies/funds to their medical needs and without residents having insurance they would not be able to be a part of that program. Interviews with S1 and S4 revealed that although there were issues with the insurance group that R1 was originally with upon admission they did provide assistance in changing the insurance, however, the insurance company did not want to release information to staff and required R1 to be present for any and all changes in which R1’s expectation was for staff to handle all the changes. LPA interviewed 11 residents and 10 out of the 11 residents denied the allegation and stated that they have not had any issues with their insurance or the set up process and stated that the staff have been helpful with their needs. Allegation: Staff did not provide good quality foods to residents in care. It is alleged that the facility has poor food. LPA toured dining/kitchen and observed a sufficient supply of perishable foods and non-perishable foods, during the lunch hour LPA observed resident meal of egg salad sandwich with watermelon, some residents ordered off the alternate menu and meals such as a caeser salad and hamburgers were provided to those residents, residents were also observed to have a dessert with their lunch including Jello, ice cream or fresh fruit. LPA reviewed the food menu and alternate menu and meals match what LPA observed during visit. LPA interviewed 6 staff and each denied the allegation and stated that they think the food is good and nutritious and have not heard complaints about the food. Interview with S1 revealed that there is a resident committee and meetings that are held with the chef and residents where preferences are discussed and chef will make adjustments to accommodate those requests and preferences when possible. LPA interviewed 11 residents and 10 out of the 11 residents denied the allegation, although some stated that some of the meals are not to their liking they did share that the alternative menu is available and they are accommodated with something different than the meal of the day when they ask. (Continued on the LIC9099-C 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 Allegation: Staff did not provide proper housekeeping services to residents in care. It is alleged that the facility has poor house cleaning. LPA toured facility a total of 7 resident rooms were inspected as well as dining area and kitchen, LPA did not observe facility to have poor housekeeping. Housekeepers and Caregivers were observed to be cleaning and throwing away trash from residents room during tour. LPA toured R1’s room and although R1’s personal belongings did appear to be scattered the room did not appear to be dirty, beds were made, floor appeared clean and trash was empty. LPA interviewed 6 staff and each denied the above allegation and stated that house keeping is done daily with the routine work such as sweeping, taking out trash and making beds, the deep cleaning is done once weekly where housekeeping will mop, dust, clean bathroom, change linens and do laundry. LPA interviewed 11 residents and 10 of the 11 residents denied the above allegation, residents stated that the minor housekeeping is done daily and a deep cleaning is done once a week, residents also stated they don’t have issues with the housekeeping. Allegation: Staff did not treat resident with respect. It is alleged that S1 yelled, humiliated, embarrassed and accused R1 of kidnapping. Per interview with R1, resident stated they are being wrongly accused of taking another resident (R12) out of the facility without any approval. LPA interviewed S1 and they denied the allegation and stated that R1 went on an outing and lied to front desk staff that they had prior permission to take R12 out of the facility on an outing, when staff left to verify R1 quickly left facility with R12, S1 stated that R12 is not able to leave facility unassisted and R1 is not listed as a responsible party for R12. LPA reviewed R12’s file and did not see R1 listed as a responsible party, R12 has only family listed as a responsible party and POA. LPA also reviewed R12’s physician report dated 2/11/25 and it indicates that resident is not able to leave facility unassisted. LPA interviewed a total of 6 staff and each denied the allegation and stated they have never nor have they ever witnessed any other staff yell, humiliate, embarrass or accuse any of the residents. Interviews with S1-S2 & S5-S4, revealed that R12 is not to leave the facility unassisted and have been advised by POA that only the POA can take R12 out of the facility unless otherwise stated/approved, which they have not yet done so. LPA interviewed a total of 11 residents and each denied the allegation and stated they have never been yelled at, humiliated, embarrassed or accused of anything by staff and say staff treat them with respect. During inspection of R1's room, LPA observed that the toilet in the private bathroom that R1 and their roommate share was not operable, LPA conducted a case management visit and issued a citation during the initial visit. Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened are is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations is UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.

The investigation revealed the following: regarding the allegation “Staff are retaliating against resident.” It is alleged that staff are retaliating against a resident. Eight (8) out of the nine (9) residents interviewed did not corroborate this allegation. Interviews with eight (8) residents revealed that staff have never retaliated against them and have always been professional when providing care. Six (6) out of the six (6) staff interviewed denied this allegation. Staff interviewed revealed that any type of mistreatment or retaliation against residents is not allowed and would report retaliation if they observed it. Review of S4-S6 personnel files did not corroborate the allegation that staff are retaliating against a resident. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. “Staff are not ensuring that resident is provided meals in a timely manner.” It is alleged that staff are not ensuring that a resident is provided with meals in a timely manner. Eight (8) out of the nine (9) residents interviewed did not corroborate this allegation. R5 and R6 revealed they have received their meals late in the past, but it was within reason, and they felt that their meals were late due to their table placement. Six (6) out of the six (6) staff interviewed denied this allegation. Staff interviews revealed that the dining room is set up as a “restaurant” style dining experience and residents’ orders are taken by servers once the resident is seated. Staff interviews revealed that once a server takes a table’s order, servers place the tickets on holder in the kitchen for the cooks but sometimes the kitchen gets backed up by plating the orders or if a resident changes their mind and orders something different, the ticket gets placed in order received. On 11/10/25, LPA Ramirez observed servers taking lunch orders and bringing meals out to resident tables. LPA Ramirez observed most meals were delivered to tables within 4 to 6 minutes of orders being placed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies were cited for this complaint investigation. A copy of this report was provided via email due to printer out of ink.

staff doing anything verbally or physically abusive. R3 and R11 stated they live over the courtyard and have not seen staff mishandling residents in a rough manner. R3- R11 also stated that staff treat them well and will help them if they ask for assistance. Administrator stated that Staff S1 said that the alleged incident never happened. Said there has not been any complaints regarding S1 previously. Staff S1 stated that the incident didn't occur. Said the alleged incident doesn't reflect on S1 as a person. Said that will comb residents hair and maybe that was misinterpreted. Also stated that residents are treated with respect and has no idea why the allegation was made. Staff S2 stated that was working PM shift and didn't see any incident. Said R1 sometimes hits staff or other residents. Stated S1 never complains and has worked 8 months with Staff S1 and has never seen anything occur with S1. Interviews conducted today 11/06/25 with Staff S1-S4 revealed that there is no additional evidence to support the allegation having occurred. Therefore the findings remain the same. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Administrator Stephanie Funderburg and copies issued.

It is also alleged that R1 was unprovoked. LPA interviewed two (2) staff that denied the allegation stating on witnessing the incident and immediately de-escalating and separating both R1 and R2. LPA interviewed an additional five (5) out of five (5) staff that all denied the allegation and stated the staff immediately intervene, separate, and re-direct residents whenever they are involved in a physical altercation. LPA interviewed R1 that denied the allegation by stating that R1 did not hurt R2 or anyone by the hallway near the dining hall. LPA interviewed R2 that denied the allegation by stating not being yelled or slapped by R2 by the hallway near the dining hall. LPA interviewed an additional four (4) out of four (4) residents denied the allegation by stating not witnessing the physical altercation between both R1 and R2. However, the four (4) out of (4) residents stated that staff immediately intervene to de-escalate verbal or physical altercations by separating the residents. LPA reviewed ongoing staff training on De-Escalating Dementia Behavior and Residents’ Rights in file. There was insufficient evidence to corroborate with the allegations. Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview was held, and a copy of this report was provided to the Executive Director, Stephanie Funderburg.

****This report supersedes the complaint investigation report dated 09/23/2025. The purpose of the visit is to add additional information not included in the report; the findings remain the same. ***** Regarding the allegation: Staff are not properly supervising a resident who may be a fall risk. It is alleged staff did not provide adequate supervision, resulting in a resident sustaining multiple hospitalization. It is alleged that R1 has had multiple falls in the facility due to lack of supervision. (8) of (8) Staff interviewed denied the allegation. (9) of (10) Residents interviewed could not corroborate the allegation. Interviews with staff showed knowledge of one fall where R1 slipped due to loss of balance related to R1’s medical condition. Staff were present and able to assess R1. 911 was also called and R1 was transported to the hospital. File review shows SIR dated 2/17/25, 3/4/25 (family was present) and 4/6/25 for the fall incident provided to licensing. There were no other recordings of falls R1 may have had in the facility. Staff stated they check on fall risk residents more frequently, every 30 minutes. During activities residents with fall risk are assisted and observed much more frequently. Based on observations, file reviews, and interviews conducted there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Regarding the allegation: Staff were not meeting residents’ personal hygiene needs. It is alleged that the staff is not meeting and providing residents with personal hygiene needs and not assisting residents to change their clothing regularly. (8) of (8) Staff interviewed denied the allegation. (9) of (10) Residents interviewed could not corroborate the allegation. According to staff interviewed, caregivers provide daily assistance services and needs to the residents in memory care (MC). Memory care staff stated they assist the residents with grooming, scheduled showers, a few residents in MC residents required assistance while other residents required full care. Residents who refuse daily living services are reproached at later time in the day. Notes are communicated to next shift staff. LPA Vaid observed MC staff assisting residents with daily living needs. Based on observations, file reviews, and interviews conducted there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. CONTINUED ON 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 ****This report supersedes the complaint investigation report dated 09/23/2025. The purpose of the visit is to add additional information not included in the report; the findings remain the same. ***** Regarding the allegation: Staff are not providing adequate food service to residents. It is alleged that staff are on their phones during mealtimes and not assisting residents with feeding and thus residents have lost a lot of weight since moving to the Memory Care Unit. Eight (8) of eight (8) Staff interviewed denied the allegation. (9) of (10) Residents interviewed could not corroborate the allegation. Staff interviewed stated that each resident in the memory care unit has meals prepared according to their dietary orders by the physician. R1's diet plan, and care plan require eating own food and encouragement but not to be fed directly. Staff have stated they however do make sure R1 finishes their meals and will assist if R1 needs it. LPA observed residents eating in the facility on their own, a few residents were observed to be semi-assisted (hand over hand) and fully assisted (residents are fed by staff) by staff. Based on observations, file reviews, and interviews conducted there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Regarding the allegation: Staff did not seek timely medical attention for resident. It is alleged that the staff did not seek timely medical attention for the resident after resident falls. Per complaint, the resident has lost a lot of weight since being at the facility. (8) of (8) Staff interviewed denied the allegation. (9) of (10) Residents interviewed could not corroborate the allegation. Staff interviews reveal that R1 care plan was created and finalized in January of 2025. This plan was communicated with R1's responsible party. File review showed last service plan on file for R1 was created on 1/26/24. According to SIR dated 2/17/25, 3/4/25 and 4/6/25 R1 was assessed by the med-techs before going to the hospital, and R1’s family and physician were notified same day. Staff stated R1 had lost weight due to the medications R1 was prescribed, staff communicated observations to family and physician. Medication dose was lowered and administered as prescribed. Based on observations, file reviews, and interviews conducted there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Exit interview was held and copy of this report was provided to Wellness Director Ruth Villa..

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced case management visit to follow up on observations during a complaint investigation visit conducted on 9/2/25. LPA met with Stephanie Funderburg and explained the reason for the visit. On 9/2/25 LPA Flores conducted a medication review during the review LPA reviewed medication list for the following residents and did not observed the medications available at the time of the visit: Resident #1(R1) On 9/2/25 LPA did not observed Hydrocodone listed as needed. On 9/19/25 a physician's order dated: 8/21/25 notes the medication was prescribed for 7 days only. Resident #2(R2) On 9/2/25 LPA did not observed Senna 8.6mg routine medication, Acetaminophen 325mg, and Oxycodone 5mg as needed medications. On 9/19/25 there are no discontinued orders. Resident #3(R3) On 9/2/25 LPA did not observed Acetaminophen 325mg prescribed as needed. On 9/12/25 LPA Flores received a picture of the bubble pack medication with original Rx date: 12/18/24. LPA interviewed R1-R3, residents stated they have not needed to ask for the medication. One resident refused to talk to LPA. A deficiency is being cited today under Title 22 Regulations. Exit interview was conducted and a copy of this report was provided.

Interviews with residents revealed 8 out of 8 residents stated they are being provided with their medications by Medication Technicians. 1 out of the 8 residents stated to have refused the medication in the evening but has been asked by med techs to take. Interviews with staff revealed medication is provided to the residents by the med-techs and it is only not provided when the resident refuses which is noted in their notes. Also the only other time a resident does not received medication is if the medication is not available due to the pharmacy not providing it. Medication review revealed medications are available for the residents, med-techs check mark their data system after providing the medication and are able to note if the resident refuses medication in the data system. Resident’s notes revealed the resident in question refused medication on two occasions. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Facility staff failed to provide assistance with activities of daily living. It is alleged staff did not provided resident with showers as schedule. Interviews with residents revealed 4 out of 8 residents do not need assistance with showers. However, staff assist them with other activities of daily living as needed. 4 out of 8 residents who require assistance with showers said they have received their showers as scheduled. However, 1 of the 4 residents, stated that they have requested a bed bath instead to an agency employee and not a facility staff, and was deny the request. Interviews with staff revealed residents are assisted with showers twice a week. Some residents are provided showers three times a week. Per staff, if a resident refuses a shower they are asked at least 3 times during that shift. If they continue to refuse, it is noted with the med-tech that they refused. If the residents request a shower on a different day, staff will provide the shower if they are available. Per documents reviewed resident in question needs full assistance with showers and are noted twice a week, no notes of shower refusal were observed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED . Regarding allegation: Facility staff retaliated against a resident . It is alleged staff retaliated against the resident by not assisting with showers due to resident not wanting to use the Hoyer lift. Interviews conducted with residents revealed 8 out of 8 residents stated staff have not responded in a retaliated manner in any situation. Per residents, staff are nice and assist as needed. Interviews with staff revealed, upon a resident refusing to shower. The staff communicate to the residents that if they are not showered the day of the scheduled shower, they may need to wait until the next schedule shower. However, they do make an effort to provide a shower if the resident had previously refused upon the residents’ request and staff have the availability during their shift. Per staff they will not respond to the resident in a retaliated manner. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. 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 staff communicate to the residents that if they are not showered the day of the scheduled shower, they may need to wait until the next schedule shower. However, they do make an effort to provide a shower if the resident had previously refused upon the residents’ request and staff have the availability during their shift. Per staff they will not respond to the resident in a retaliated manner. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Stephanie Funderburg and a copy of this report was provided.

The investigation revealed the following: regarding the allegation “Staff prohibit resident from leaving the facility.” It is alleged staff prohibit resident#1 (R1) from leaving the facility. LPA Ramirez reviewed and obtained a copy of R1’s physician’s report, which revealed that R1 may not leave the facility unassisted. Interview with resident#1 (R1) revealed that R1 enjoys going on outings when R1 chooses to sign up for an outing. Five (5) out of the five (5) staff interviewed denied the allegation. Five (5) out of the six (6) residents interviewed denied the allegation. Interview with Staff#1 (S1) revealed that R1 may not leave the facility unassisted however, the facility offers in-house activities and community outings. S1 revealed residents can sign up for community outings if they choose to do so. LPA Ramirez reviewed and obtained a copy of the facility posted Activities Schedule for the months of August 2025 and July 2025. LPA Ramirez observed several community outings listed including, mornings walks, outings to museums, local ice cream parlors, local restaurants, local retail stores and local movie theaters. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . No deficiencies were cited. Exit interview was conducted. A copy of this report was provided via email.

In regard to the allegation “Staff retained resident that requires a higher level of care “, it is alleged that staff did not adequately meet R1’s needs. During interviews with Administrator and staff six (6) out of six (6) staff stated that facility meets all the needs of all residents. Administrator stated that facility provides end of life services for residents and are more than qualified to handle non ambulatory residents and residents who require a high level of care. It was also stated that R1 did go from a level 1 care to a level 5 care therefore more services were provided but at no time did a physician state that he needed a higher level of care than what the facility could provide. During interviews with residents eight (8) out of nine (9) residents felt they received good quality of care by staff. R4 stated that overall, all needs have been met and staff is cordial to residents. In regard to the allegation “Staff do not ensure that resident is transported to medical appointments “, It is alleged staff did not provide transportation to resident due to nonpayment of rent. During interviews with Administrator and staff six (6) out of six (6) staff stated that transportation is arranged with front desk and residents are never denied service regardless of nonpayment of rent. Administrator stated there are many residents that don’t pay, and facility has never stopped rendering services because of that. During interviews with residents three (3) residents stated that they have never needed transportation, two (2) residents stated that they need to make arrangement a week in advance, and four (4) residents stated they have had no problems with transportation. In regard to the allegation “Staff do not ensure that resident's hygiene needs are met “, it is alleged that R1 smelled strongly of urine as well as wheelchair. During interviews with Administrator and staff four (4) out of six (6) stated that residents are always changed and showered. Two (2) staff stated that there has been a couple of incidents that they have found residents soiled in the morning shift and that gets reported right away. During interviews with residents seven (7) out of nine (9) stated that they have never had any problems with being left soiled nor ever witnessed residents being left soiled. R2 stated that they had witnessed R1 being changed 2 or 3 times a day by staff. SEE 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 In regard to the allegation “Staff do not accord resident dignity in their relationship with staff “, it is alleged staff can be mean and rude to residents. During interviews with Administrator and staff six (6) out of six (6) stated that they have never witnessed staff treat residents rude. Administrator stated there has been no write ups or disciplinary actions for this type of behavior. During interviews with residents eight (8) out of nine (9) residents stated that staff has not been rude or disrespectful to them. R3 stated that staff shows him/her the “most respect”. In regard to the allegation “Staff handle resident in a rough manner”, it is alleged that staff jerks’ residents around. During interviews with Administrator and staff six (6) out of six (6) stated that no residents has ever told them that staff jerks them around. All staff stated that if they had heard staff was mistreating residents that it would be reported. During interviews with residents eight (8) out of nine (9) residents stated that staff has never handled them in a rough manner nor have they witnessed other residents being handled rough. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was given to Administrator.

LPA interviewed R1 during the visit today. R1 recalled 2 staff being rough while trying to get the resident to the showers. R1 stated that one of the staff was frustrated and said to “get in the shower.” R1 did not recall the staff names and stated that it was the only time R1 had seen them working. LPA interviewed the administrator and 7 staff, which included the agency staff who worked during the time of the incident. Staff interviewed stated they have not observed any staff physically or mentally abusing residents in care. They will report it if they see any staff being abusive or aggressive. They stated that they receive annual training on how to properly transfer residents to prevent injuries. Regarding Resident #1, they stated they did not notice any bruises on the resident’s hands or arms until the police came to investigate. R1 did not mention any abuse or roughness prior to the police visit on 4/15/25. It was reported that R1 obtained bruises to the left and right arms during a shower transfer in March 2025. Staff interviewed denied being rough with R1 during transfers and stated they would ask other staff to assist with transferring R1. According to the administrator, there were no reports of staff being rough or injuring R1 during transfers. An additional nine residents interviewed have not been hurt or injured by staff. They stated the staff are respectful and careful. They have not seen any staff abusing residents in any way. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted with the administrator. A copy of this report, along with the appeal rights, was provided.

One out of ten (1 out of 10) residents was unable to answer interview due to cognitive skills. Interviews with staff revealed residents are encouraged to eat their meals and assisted when needed. Per staff, if changes in condition are noticed they are noted in the resident chart notes. Medication Technician then follow up with physician and/or family members. Administrator stated staff did observed R1’s food intake decreased. However, R1’s physician was conducting visit. On 5/2/25, R1’s physician recommended nutritional shake to be increase. Documents reviewed revealed R1’s physician’s report dated: 1/2/25 notes, R1 has a special diet due to health condition. R1’s service plan dated: 3/5/25 notes R1 will obtain assistance with cutting and preparing food or prompting throughout the meal. Medical evaluation conducted on 2/24/25 notes R1 is consuming three meals a day. Facility’s notes from 4/7/25 – 5/12/25 note R1 refused to eat on 4/7/25, 4/18/25, 5/3/25. Physician visited R1 on 3/20/25, 4/23/25,5/2/25. Physician’s order dated: 5/2/25 note an increase from 1 to 3 nutrition shakes a day for R1. Although R1 did seem to have had a change in condition. Per interviews conducted facility staff have assisted R1 with food intake and physician’s follow ups/visits. Therefore, this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Stephanie Funderburg Administrator and a copy of this report was provided.

The investigation revealed the following: Regarding allegation: Staff do not respond to resident’s call for assistance, and Staff did not assist resident after a fall . It is alleged R1 fell between 12/30/24 and 1/1/25, and pressed the call button for assistance, and staff did not come to assist. Interviews conducted with residents revealed staff have responded to resident’s pendant call and assisted them when needed. Interviews with staff revealed staff respond to the pendant call as soon as possible. Per staff, it may take staff longer to respond if they are assisting other residents with something they cannot leave unattended. Documents review revealed pendant call was pressed for R1 on 1/1/25 at 5:19pm, front desk acknowledges R1 at 5:30pm, and a staff responded and clear pendant call at 5:52pm. Between 12/30/24-12/31/24, R1 pressed the pendant call button 7 times and each was cleared by a staff. There are no incident reports or notes to note R1 fell on/or before 1/1/25 and requested assistance. Although R1 pressed the pendant button on 1/1/25 it is uncertain the reason of the call as residents use the pendant call for assistance with different things as well as for emergencies. Desk acknowledges the call to the residents to ensure the immediate need and proper response. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff did not notify resident’s responsible party of fall. It is alleged responsible party was not notified by staff of the fall. Interviews conducted with residents revealed staff either notifies or are certain staff will notify responsible parties if an incident occurs. Interviews with staff revealed when a fall occurs the Med-Tech notifies the responsible party/family of the incident. Documents review revealed R1 is self-responsible, per Emergency Information Sheet signed and dated on 9/28/24. Per incident report dated 1/3/25, R1’s family member was contacted and notify of incident. Per incident report dated 1/5/25, R1’s family member was contacted. Notes on internal incident report dated 1/5/25 note staff was unable to contact family member or leave a voice message after three attempts. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff do not ensure facility is free of bad odors. It is alleged that the hallway smelled of feces and urine. Interviews with residents revealed the facility does not have bad odors throughout. (CONTINUED ON LIC 9099C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Interviews with staff revealed odors are only noticed when a resident with incontinence has had a bowel movement or urinated. Caregivers stated to clean residents timely and ensure that items are properly disposed, and contact housekeepers if additional cleaning is necessary. On 1/7/24 LPA conducted a tour of the facility and did not notice any bad odors throughout the facility. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff are not safeguarding resident’s belongings. It is alleged a blood pressure machine purchase by R1’s representative was missing. Interviews conducted with residents revealed residents have not lost any items. One resident stated to have misplace items and staff assisted to find them. Interviews with staff revealed residents usually report to staff when they lose something, and residents have not reported any lost items within the last two months. LPA reviewed R1’s Resident Personal Property and Valuables sheet dated and signed on 9/27/24 and notes R1 “decline to track personal property”. Although the item may have gotten lost, there are no documents that record the missing item and there were no reports to staff of the item getting lost per interviews conducted. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff do not ensure resident has privacy in their room. It is alleged that staff do not knock before entering the room. Interviews with residents revealed staff knock at the door before entering their room. Interviews with staff revealed staff knock at the door before entering the room and let the residents know they are coming in. On 1/7/25 during the tour of the facility, LPA observed staff knock before entering each room visited. LPA also observed other staff knock at the door before entering the rooms to check on residents. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED . (CONTINUED ON LIC 9099C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Regarding allegation: Staff did not notify responsible party of resident’s room change . It is alleged staff did not notify responsible party of R1’s room change. Interviews conducted with residents revealed residents believe their family members will be notify of any incidents or changes regarding their care. Interviews with staff revealed Med-Tech or administrative staff are the ones who notify family members of incidents or changes in the residents’ care. Per administrator R1 was aware that a room change will take place and R1’s family member was present during the notification of the last room change. Document review revealed Emergency Information Sheet signed and dated on 9/28/24, notes R1 is self-responsible. There were no emergency contacts listed other than R1’s physician. Due to records noting R1 is self-responsible the facility is not responsible for notifying additional parties. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff’s negligence let to resident’s fall. It is alleged R1 fell on 1/5/25 due to staff not locking the brakes on the wheelchair. Interviews conducted with residents revealed staff ensure residents safety. Residents have observed staff locking wheelchair when assisting residents to the dining room or other places. Interviews conducted with staff revealed staff are familiar with safety precautions for residents using a wheelchair and ensure that the wheelchair brakes are lock when they come to a full stop. Documents review revealed, incident report dated 1/5/25 notes R1 fell while attempting to scoot self in the wheelchair while staff were assisting to push R1’s wheelchair in their apartment. Facility staff called emergency personnel and R1 refused to go to the hospital. Although, R1 did suffer a fall on 1/5/25 there is no evidence to support R1 fell due to wheelchair brakes being unlock due to staff neglect. Therefore, the allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview was conducted and a copy of this report was provided.

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced case management - health and safety check visit regarding reported incident on relocation of 2 residents from Foothill Heights Care Center due to mandatory evacuation orders from the Fire Advisory. LPA met with Michelle Castillo and explained the reason for the visit. During the visit today, LPA Flores conducted a health and safety check by touring the facility. No immediate health and safety concerns were observed. LPA obtained a copy of the resident and staff roster. Per interview with the administrator, there are 2 residents that have been relocated from Foothill Heights Care Center. Facility is fully staff and nurses have been visiting the 2 residents daily. Administrator has been in contact with Pasadena Public Health Nurse and Ombudsman, who have visited the residents. Food and hygiene supplies are available to accommodate all the residents. LPA reviewed medications and MAR logs for the 2 residents that were transferred to the facility and are centrally stored and inaccessible to the residents. The last fire drill was conducted on 12/17/24. LPA discussed with administrator proper relocation of resident #1 who has a prohibited health condition and there is no enrollment in hospice care. Per administrator they are currently working on it. Due to the situation most skill nursing facilities are full at this time. However, will continue to seek proper placement. An exit interview was held and a copy of this report was given to the Stephanie Funderburg Administrator and a copy of this report was provided.

Administrator attempted to resolve the situation by providing staff to assist R2 to store the items in the boxes and offered to purchase additional storing space for R2. However, R2 refused. During the tour of the facility LPA did not observe any personal belongings or boxes stored in the showers of each residents’ room. A closet and drawers were observed in each room assigned to each resident. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff do not ensure the resident’s hygiene needs are being met. It is alleged residents have not been assisted with showers in almost a month and their bedding is not maintain clean and free of feces. Interviews with residents revealed residents are assisted with showers and are provided a shower at least twice a week. Some residents stated that they are independent and are able to take a shower on their own and had no concerns regarding access to their personal shower. A few residents stated they rather use the common shower when necessary. Interviews with staff revealed residents are schedule to be assisted with showers twice a week. However, if a resident chooses to shower more often, they assist them as needed or if the if the staff determine the resident needs a shower for any reason, they are provided a shower more frequent. Per staff there is a large communal shower that is accessible to the residents for easiest access. Per staff schedule residents are assisted with showers. Per Service plans reviewed residents are receiving assistance with bathing “2x per week”. Per staff assignment chart residents are assisted R1 is assisted with showers on Sundays and Wednesdays and R2 is assisted with showers on Tuesdays and Thursdays. During LPAs toured beds were observed clean, free of debris, and feces. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Stephanie Funderburg and a copy of this report was provided.

Interviews conducted with residents revealed 3 out of 6 residents stated staff have been seen wearing gloves and mask while providing care. 2 out of 6 residents stated staff were sometimes not wearing proper PPE when providing care. 1 out of 6 residents stated to not be aware of breakout. Interviews with staff revealed staff were informed of symptomatic residents on 11/18/24 and staff implemented wearing PPE, resident isolation, and were provided training. On 11/20/24 a server was observed providing meals in residents rooms without changing gloves in between residents during a visit provided by PDPH. On 11/22/24 staff was observed not implementing proper hand hygiene procedures per PDPH. Training was provided to staff on 11/17/24 on Infection control, and on 11/22/24 training was provided on disinfecting, PPE proper use, and hand hygiene. Although the residents and staff stated to have been following guidance to prevent the spread. Visits conducted by PDPH revealed staff did not follow hand washing and glove changing guidance. Therefore, allegation is substantiated. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. Regarding allegation: Staff are not following infection control requirements. It is alleged facility staff enter a resident’s room with infections disease symptoms and did not use proper Personal Protective Equipment (PPE). On 11/19/24 emergency personnel responded to a call upon entering a resident’s room with symptoms of infectious disease facility staff assisting did not put on proper PPE prior entering the room. Interviews conducted with residents revealed the following 3 out of 6 residents stated staff used proper PPE when entering the rooms to provide care. 3 out of 6 residents either did not observe or remembered whether staff used proper PPE supplies. Interviews with staff revealed staff were provided PPE supplies which were placed outside residents’ rooms that were in isolation. However, staff admitted that during the visit of emergency responder, staff was not wearing PPE when assisting resident with infectious disease symptoms going out to the hospital. During facility’s tour, LPA observed PPE supplies in 3 rooms who are currently in isolation. One staff was observed going into a resident’s room to provide care with face mask under the chin as staff walked to provide care into resident’s room. Although facility has implemented guidelines and provided training to staff, staff did not follow infection control guidance. Therefore, this allegation is substantiated. (CONTINUED ON LIC 9099C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Based on LPAs observations, interviews which were conducted, and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED . California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Deficiency was noted on LIC 9099D on report dated 11/26/24. Exit interview was conducted with Stephanie Funderburg and a copy of this report, LIC 9099D, and appeal rights were provided. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Facility reported outbreak to Community Care Licensing (CCLD) on 11/17/24 and to PDPH on 11/18/24. Families, residents, and staff were notified of outbreak on 11/18/24 via letter. On 11/19/24 facility personnel responded to a call at the facility. Staff in charge did not notify personnel of outbreak. Although the facility staff did not informed emergency personnel regarding outbreak at the facility. Facility administration notified CCLD and PDPH within 24 hours of the third resident with symptoms. Regulation stated an outbreak must be notify to CCLD and PDPH. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview was conducted with Stephanie Funderburg and a copy of this report was provided.

Interviews conducted with staff revealed, R2 had trip and fallen in the dining room on 4/18/24. Staff assisted R2, who was send out to the hospital via emergency services. Interview conducted with R2’s family member who was present during the fall revealed R2 made a sudden turn and fell, sustaining a hip fracture. Per family member facility staff assisted right away, paramedics were called, and R2 was send out to the hospital. While at the hospital R2 was not able to obtain surgery for the hip fracture due to other health conditions and passed away on 4/25/24 at the hospital. Documents reviewed revealed, Incident report dated 4/22/24, notes R2 suffered a mechanical fall in the dining room on 4/18/24 at 5:30pm. Paramedics were called and was transferred to the hospital. Service Plan dated 12/28/23 notes R2 is independent, self-care, with occasionally needing verbal cues. Per physician’s report dated 5/1/23 R2 did not have any motor impairments. Regarding R3, interview conducted with administrator revealed R3 had been at the facility for about 4 weeks and did not show any changes in condition or other signs of distress. On 7/10/24, staff conducting checks found R3 in the room unresponsive. Paramedics were called and R3 was declared death. Documents reviewed revealed the following: Per incident report dated 7/9/24, R3 was found in the room on 7/3/24 at approximately 12pm by a caregiver not responding to verbal commands. R3 was assessed by medication technician, who observed R3 was weak, vomiting, and unresponsive to verbal commands. Emergency services were called and R3 was transfer to the hospital. R3 was hospitalize, received treatment, and return to the facility on 7/8/24. R3’s physician’s report dated: 5/16/24 notes R3 had a history of congestive heart failure. Death report dated 7/10/24 notes, on 7/9/24 R3 was found in their room by a medication technician during check rounds. Paramedics were contacted, arrived at the facility, after evaluating R3 declared time of death at 7:42pm. Death report notes cause of death as cardiopulmonary arrest. Although both deaths were sudden there were no changes in condition, prevention, or lack of staff care that could have prevented the deaths of R2 and R3. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff are not providing adequate food service to resident. It is alleged R1 was on a vegan food program. However, R1 was forced to buy own vegan food for the chef to cook and was not provided vegan meals by the facility. Interviews conducted with residents revealed facility facilitates meals to residents’ dietary needs or preferences and are satisfied with the meals provided. (CONTINUED ON LIC 9099C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Interviews with staff revealed facility staff are able to identify residents with special diets, allergies, or meal preferences which they follow to provide the meals to the residents in care. Kitchen staff are aware of R1’s vegan meals preference and arrange for R1 to received vegan meals daily. Interview with Culinary Director revealed R1 had shown a desired for certain products that the facility was not able to accommodate as food produce vendor did not carry does specific items. However, culinary director had accommodated other brands or substitutes to provide the meals for R1. Document review revealed R1’s facility’s nutritional profile dated 3/22/24 notes vegetarian meals. Physician’s report dated 3/21/24 notes R1 has a vegetarian diet with regular textures. Although R1 may have had preferences in vegan items or produce, interviews conducted revealed the facility provided vegan meals for R1 with accommodations of produce they were able to obtain with food company they vendor with. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff are not meeting residents needs. It is alleged facility staff are not assisting residents with dementia to seat at the dining room table and wheels of residents in wheelchairs are getting stuck in the elevators’ gaps. Interviews conducted with residents revealed residents feel satisfied with the care and assistance the staff are providing to them. Residents that need assistance with wheelchairs stated to be able to get into the elevator without difficulties and wheels have not gotten stuck in the gaps of the elevator. Interviews with staff revealed, at mealtimes staff remind residents to their usual chair when they seem confused and are not left unattended. Also, staff assisting residents in wheelchairs have not have incidents in which wheels get stuck in between the gaps or the elevators’ doorway. During facility’s tour on 8/27/24 LPA observed facility’s elevators in working condition and no large gaps were observed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Stephanie Funderburg and a copy of this report was provided.

Interviews with staff revealed R1 was leaving the facility on an outing, facility’s driver assisted R1 standing near R1 and providing hand for support. R1 place her hand on driver and used her left hand on the van’s handle to pull self-up. As R1 was lifting self-up to get into the van, R1 cried out in pain and stated to have “pop my knee”. Staff called emergency services for R1 who arrived right away and was taken to the hospital by paramedics. Documents reviewed revealed, per physician’s report dated 3/21/24, R1 is ambulatory and does not have any physical impairments. Incident report dated 8/6/24 notes R1 was going in an outing and was “stepping into the community bus assisted by facility’s driver. Upon R1 stepping into the bus, R1 stated to have heard a snap in the knee and was unable to bear weight”. A medication technician assessed R1 and 911 was called to send R1 to the hospital. Per preplacement appraisal information dated 3/29/24 R1 had a “prior broken left femur”, hip and knee. Resident Assessment dated 3/20/24 notes R1 is “independent, self care”. Although R1 may have sustained a fracture, the fracture was not due to hazardous or the facility not being safe. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED . Regarding allegation: Staff did not prevent the facility from being hazardous resulting in residents sustaining injuries. It is alleged the facility is not safe and they are having "things" in places where they shouldn't be causing residents to fall many times and have gotten injured. Interviews with residents revealed they have not observed hazardous materials or construction materials left in hallways or common areas. Interviews conducted with staff revealed there has been some remodeling done at the facility. However, the tools and materials are kept inside the rooms being remodel and not in common areas or corridors. During the tour of the facility LPA observed the remodel rooms. No hazardous materials or tools were observed in the hallways or common areas. Incident reports submitted within the last month to the department note falls due to other reasons. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED . Regarding allegation: Staff did not prevent facility from being in disrepair. It is alleged shower stopped working and the A/C unit also stopped working. Interviews conducted with residents revealed shower and A/C has been in working condition and had no concerns. (CONTINUED ON LIC 9099C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Interviews with staff revealed facility’s A/C has been in working condition and no reports of clogged showers had been made. During facility tour a total of 12 resident rooms were observed and each shower/bathroom was in working condition. Temperature in each room was felt comfortable and A/C was working. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff did not follow physician’s order. It is alleged resident did not receive physical therapy for eight weeks due to facility lying agency about whereabouts of resident. Interviews with residents revealed residents are assisted as needed with all their needs. Interview with administrator revealed R1 was not receiving physical therapy or had orders for physical therapy. Documents reviewed revealed Skill Nursing order summary report dated 1/31/24 notes R1 was to received physical therapy, “one time only” until 2/25/24. No other physician orders were observed in R1’s file pertaining most recent physician’s order for physical therapy. Resident Assessment dated 3/20/24 notes R1 is independent to coordinate own healthcare and home care appointments. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff did not prevent resident’s sleep from being interfered. It is alleged resident’s roommate snored loudly and resident could never sleep. Interviews conducted with residents revealed staff responds to residents’ concerns when necessary and have not experience issues with roommates. Interview with administrator revealed, R1 reported the situation. R1’s roommate was moved from room due to residents not getting alone. R1’s roommate was interview and was not able to recall any incidents with roommates. Although the situation may have happened there is not enough evidence to say that the facility did not take action in assisting R1 after reporting R1’s concerns. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Stephanie Funderburg and a copy of this report was provided.

The investigation revealed the following: Allegation: Staff are not preventing the spread of COVID-19. LPA toured facility alongside of Stephanie Funderburg (Executive Director) and Ann-Marie Boersma (Wellness Director) and observed hand sanitizing stations throughout facility, LPA tested the sanitizing stations in common areas and they were operable. There is one resident that was recently on isolation (last day was yesterday), signage of corona virus was at the door and there was a sanitizing station with masks, gloves, gowns, and hand sanitizer outside of their room. LPA observed a storage room in memory care that had sufficient PPE supplies, such as masks, gloves, gowns and hand sanitizer. LPA obtained copies of letters informing Residents and Family/Responsible parties that were sent out, informing them that there have been Covid Positive cases and encouraging all to wear masks, as well as staff. Throughout the tour LPA observed multiple staff and residents without masks, however, given the recent Rescission of Health Officer Order for the City of Pasadena as of March 5,2024, the order requiring masks by personnel, patients, clients and visitors in health care settings issued March 29.2023 by the health officer of the City of Pasadena is rescinded in its entirety, this information was provided to LPA by the Department of Public Health. LPA interviewed 12 Residents and 10 out of 12 Residents denied the above allegation. 10 residents stated that have observed staff wearing masks and have masks and hand sanitizer readily available for them, they also stated that they were informed of the outbreak and encouraged to wear masks. LPA interviewed 5 staff and 5 out of staff denied the above allegation and stated that they have been encouraging masks, sanitizing and have notified residents of the outbreak. LPA special incident reports that were submitted to licensing, and noticed that the Covid outbreak was not reported per the 24 hour reporting requirement. This will be detailed in a separate case management report. Based on statements and interviews conducted with staff and residents, review of documents/records, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview held, and a copy of this report was provided.