Oakmont of Redwood City.

Based on documents reviewed, the facility received an order from Pine Park Health on 8/8/25, instructing the facility to discontinue Donepezil, start Olanzapine (2.5mg) every day, and increase dosage of Lexapro to 10mg. Based on the MAR reviewed, R1 was receiving Donepezil since admission until August 8, 2025 when Pine Park Health instructed the facility to discontinue. MAR reviewed showed Olanzapine (2.5mg) and Lexapro (10mg) was being administered as prescribed. On August 19, 2025, a new order was sent from Pine Park Health to discontinue the Olanzapine and Lexapro. LPA reviewed R1's current MAR and current prescribed medication list, centrally stored medication list was up to date. Based on documents reviewed and information collected, the department has determined that although the above allegation may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are UNSUBSTANTIATED. Report is reviewed with Administrator, Jennifer Duenas and a copy is provided.

Regarding the allegation, staff do not ensure the facility is clean and sanitary, according to the reporting party, staff were not taking out R1's trash and it was overflowing. During the investigation, LPA reviewed R1's service plan and observed a random sample of rooms, including R1's room at the time. Based on observations, rooms were observed to be clean and odor-free. LPA did not observe trash on the room floors. Based on R1's service plan reviewed, R1 required no assistance beyond routine weekly housekeeping. According to staff interviewed, and R1's charting notes, R1 refused housekeeping/cleaning services. Regarding the allegation, staff do not ensure resident's laundry is being done, according to the reporting party, it was observed R1's laundry was sitting in a pile on the floor and was not done. During the investigation, LPA reviewed R1's file and interviewed staff. LPA was unable to interview R1 as R1 passed away. According to R1's service plan, R1 required weekly laundry service and independently manages additional laundry needs. According to staff interviewed, and R1's charting notes, R1 refused housekeeping/cleaning services. Regarding the allegation, staff do not ensure resident's bedding is clean, according to the reporting party, it was observed that R1's bedding was soiled. During the investigation, LPA toured and observed a random sample of rooms including R1's room at the time. and interviewed staff. LPA observed all rooms to have clean bedding. According to staff interviewed, laundry is done once a week per residency agreement, however if residents require laundry to be done more often then it would be added to their service plan. According to staff interviewed, and R1's charting notes, R1 refused housekeeping/cleaning services. Regarding the allegation, staff are mismanaging resident's medications, according to the reporting party, on 2/10/26, R1's hospice nurse called R1's responsible party to notify him/her that R1's morphine was missing and that R1 did not receive morphine for a week. (continue to 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 During the investigation, LPA reviewed R1's MAR, prescribed medication list, R1's medication destruction log and interviewed the Regional Operations Specialist. According to R1's MAR and prescribed medication list, R1 was prescribed morphine on 12/24/25 and received morphine by mouth every 2-4 hours as needed. According to documents reviewed, R1's physician ordered the facility to discontinue the administration of morphine for R1 on 1/1/26. Medication destruction log notes that the morphine was destructed on 2/26/26. Regarding the allegation, staff do not respond to resident's calls for assistance, according to the reporting party, there were days where R1's pendant was pressed, however no staff responded. During the investigation, LPA reviewed R1's call pendant log and interviewed residents. Based on R1's call pendant reviewed during the time R1 was a resident at the facility, the average response time was 18 minutes. According to residents interviewed, when they call for assistance, staff respond timely and help them. Regarding the allegation, staff do not ensure resident's incontinence needs are being met, according to the reporting party, R1 was wet from his/her waist to ankles and no one changed him/her, so the hospice nurse ended up changing R1. During the investigation, LPA reviewed R1's file and interviewed staff. LPA was unable to interview R1 as R1 passed away. Based on R1's physician's report , R1 is unable to care for his/her own toileting needs, wear depends and requires caregiver assistance. According to R1's service plan, R1 was occasionally incontinent of bladder and/or bowel and occasionally required staff assistance. According to R1's charting notes and staff interviews, there were several times, R1 refused to be changed by staff when his/her depends was soiled. Regarding the allegation, staff did not provide copy of resident's admission agreement to resident's representative, according to the reporting party, despite providing POA documents to the facility for R1, when he/she asked for R1's admissions agreement, the Director did not provide it and stated to get it from R1. During the investigation, LPA interviewed Regional Operations Specialist, and reviewed R1's file. (continue to 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 According to the Regional Operations Specialist, she denied this allegation and indicated that the individual that was asking for R1's admissions agreement did not provide any documentation to the facility to show that they were R1's responsible party or POA. In addition, based on R1's file reviewed, there were no POA documents and R1's emergency contact sheet signed on 12/3/25 did not list the individual who was requesting the admissions agreement nor did it list a medical POA. According to the Regional Operations Specialist, she provided R1 a copy of his/her admissions agreement and notified the individual that he/she can get it from R1. Based on documents reviewed, information collected, and interviews conducted, the department has determined that although the above allegation may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are UNSUBSTANTIATED. Report is reviewed with Administrator, Jennifer Duenas and a copy is provided.

Although the charge for care fees are being billed at $3,640.75/month, with the credit of $296.75 being applied, the total monthly care fees are $3,344/month. Based on the accounting ledger for R1, in October 2025, R1 was charged $3,640.75/month, however, was credited back $10.038.78. According to documents reviewed and interviews conducted, R1’s care level was higher prior to 7/1/2023 – date of transition and the care point assessed after the transition was at 177, which at the time totaled $3,434, which continued to be charged at that rate until January 2025. The care rate increased from $21 to $22 and all residents were transferred over from the 2024 assessment tool to the 2025 assessment tool for the new rate to take effect. That’s when the 2025 rate for care reflected $3,640.75. Because R1’s account was considered “legacy” his/her care rate was grand fathered in at the locked-in rate for the first 152 points and therefore, would generate a credit difference between the 2024 care rate and 2025 care rate. According to staff interviewed and emails reviewed, R1’s responsible party agreed to this care assessment and care amount of $3,434 on date of transition, 7/1/2023, however, Oakmont Management did not understand why refunds were being requested from R1’s responsible party. On 10/17/25, Oakmont’s Regional Director of Operations emailed R1’s responsible party and indicated that an immediate goodwill credit of $10,038.78 will be returned to R1’s responsible party. Regarding the allegation, facility staff are not honoring the terms and conditions of the admission agreement, according to the reporting party, Resident 1’s (R1’s) the facility is not honoring the billing terms tied to the care point system in the admission agreement with Sunrise Senior Living had. According to staff interviews and documents reviewed, after Oakmont Management Company took over Sunrise Senior Living the billing is different. Sunrise Senior Living calculated care in a different way to Oakmont and the translation of care services from Sunrise's point system to Oakmont's is a computer algorithm based on services provided. There's not a specific dollar per point during the transition from Sunrise. At that time, R1's care services equated to 152 points and that point total doesn't change unless R1 switches to an Oakmont residency agreement. Based on documents reviewed, information collected, and interviews conducted, the department has determined that although the above allegation may have happened or are valid, there is no a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation is UNSUBSTANTIATED. Report is reviewed with Administrator, Jennifer Duenas and a copy is provided.

In addition, according to staff interviewed and documentation reviewed, the computer system for the call pendants were down for less than 24 hours. The facility immediately started taking steps to fix this issue as soon as it was brought up. Staff indicated that while the call pendants were in disrepair, the Regional Health Services Director implemented status checks on residents and staff increased resident checks to every 30 minutes to an hour or as needed based on resident needs. Based on documents reviewed, information collected, and interviews conducted, the department has determined that although the above allegation may have happened or are valid, there is no a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation is UNSUBSTANTIATED. Report is reviewed with Administrator, Jennifer Duenas and a copy is provided.

On February 26, 2026, Licensing Program Analyst (LPA) Komal Curley conducted a Case Management-Other visit to the facility. LPA met with Regional Operations Specialist, Caroline Frangieh and explained the purpose of the visit. The purpose of this visit is to follow up on a "Decision and Order" for the exclusion of Staff 1 (S1) and Staff 2 (2) and revocation of administrator certificate for Staff (3). During the visit, Regional Operations Specialist confirmed that S1-S3 no longer are employed with the facility. No citations are issued during the visit. Report is reviewed with Operations Specialist, Caroline Frangieh and a copy is provided.

On November 4, 2025, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced annual inspection. LPA met with Regional Operations Specialist, Tammie Sampedro and explained the purpose of the visit. LPA toured the facility inside and outside including all of resident rooms, common areas & kitchen. The indoor and outdoor passageway was free of obstruction. No accessible bodies of water of fire safety hazards observed. This is a two building facility; Assisted Living (AL) and Memory Care (MC). AL has three floors and MC has two floors. A random sample of resident rooms in AL and MC were toured. All resident rooms were observed clean, odor-free, equipped with all required furniture. Resident bathrooms and communal bathrooms were observed to clean and in good repair. Water temperature throughout the facility measured within regulatory requirements. Communal areas including but not limited to dining room, living rooms, private dining area, etc. were observed free from tripping hazards. A comfortable temperature is maintained and lighting is sufficient for comfort. LPA observed two day perishables and seven day non-perishables. Medications, sharps, and chemicals were observed locked an inaccessible to residents in care. Carbon monoxide monitors are working properly. All fire extinguishers have been checked and current as of October 2024. Emergency drills are logged and done every three month. LPA reviewed 5 resident records and 5 staff records. Resident records are updated, complete and signed. Staff records are complete, with training logs that have met the basic requirement. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated. No citations are issued during the visit. Report is reviewed with Regional Operations Specialist, Tammie Sampedro and a copy is provided.

On November 4, 2025, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced case-management visit. LPA met with Regional Operations Specialist, Tammie Sampedro and explained the purpose of the visit. The purpose of today's visit is to deliver an immediate exclusion letter to exclude a Staff 1 (S1) from the facility. The letter was given to the Regional Operations Specialist, Tammie Sampedro. This report is reviewed and discussed with the Regional Operations Specialist, Tammie Sampedro and a copy is provided.

On August 5, 2025, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced case management visit. LPA met with Interim Executive Director, Kathleen Olson and explained the purpose of the visit. The purpose of today's visit is to deliver an immediate exclusion letter to exclude Staff #1 (S1) from the facility. The letter was given to the Interim Executive Director, Kathleen Olson. This report is reviewed and discussed with the Interim Executive Director and a copy is provided.

On July 22, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit in relation to an incident that occurred on 7/9/25, however was reported to CCLD on 7/12/25. LPA met with Interim Executive Director, Kathleen Olson and explained the purpose of the visit. On 7/12/25, the Licensee reported that on 7/9/25, it was alleged that Staff 1 (S1) took an unauthorized video of Resident 1 (R1) on S1's personal phone while R1 was sleeping in only his/her pull ups. It was heard on the video that S1 was laughing at R1 and called R1 a mermaid. In the video it was observed that S1 physically abused R1. on 7/12/25, Staff 2 (S2) reported this incident and indicated that S1 showed S2 the video. An investigation was conducted, however S1 resigned at the time of the investigation. During the investigation, LPA collected documents and interviewed staff. Further investigation is required. Report is reviewed with the Interim Executive Director and a copy of the report is provided.

In addition, staff interviewed had conflicting information on whether R1 was a fall risk or not. Facility staff were unaware of R1's injuries and did not document or notice any changes in condition nor how the injury could have been sustained. Based on medical records, on 10/13/24, R1 was transported to the hospital and three x-ray views of R1's left hip did not show any fracture at the time. Further evaluation with cross-sectional imagining was recommended and conducted on 10/16/24 where a computed tomography (CT) scan was conduct of his/her left hip for a possible fall. Medical documentation indicated that the CT scan showed that R1 had an acute non-displaced fracture through the base of the left superior pubic ramus and through the mid left inferior pubic ramus. Based on the investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Failure to correct said deficiencies may result in additional civil penalties. AN IMMEDIATE CIVIL PENALTY OF $500.00 WAS ASSESSED TODAY: $500 FOR THE VIOLATION AS R1 SUSTAINED UNEXPLAINED FRACTURE WHILE IN CARE. A repeat civil penalty of $500 was issued today due to the same violation being cited on 5/27/25. Due to immediate civil penatly of $500 being cited and repeat civil penalty of $500 being cited, total civil penalty being issued today is $1,000 THE INTERIM EXECUTIVE DIRECTOR WAS INFORMED THAT AN ADDITIONAL CIVIL PENALTY IS STILL BEING DETERMINED AND MIGHT BE ASSESSED BASED ON HEALTH AND SAFETY CODE §1569.49. Report is reviewed with the Interim Executive Director and a copy is provided with appeal rights. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Regarding the allegation, facility staff are not cleaning resident's room, according to the reporting party, on 10/13/24, it was observed that R1's room was filthy, with soiled bed linens, old, soiled clothing, and urine pads on the floor. During the investigation, LPA toured the facility and observed a random sample of eight resident rooms including R1's room. Based on observations, rooms toured were observed to be clean, odor-free, and with clean bed linens. During the visit, LPA was notified that R1 was no longer a resident at the facility. According to staff interviewed, there are two housekeepers on shift in the AM and two housekeepers in the PM. Housekeepers are deep cleaning rooms every week, taking out trash from resident's room per shift and doing laundry as needed. In addition, staff interviewed indicated that every shift change, caregivers will check each resident rooms to make beds and collect trash at the beginning and at the end of each shift. Regarding the allegation, facility staff did not communicate with authorized representative(s) on resident changes in health condition, according to the reporting party, the facility staff did not know how or when R1 suffered a fracture and did not notify R1's authorized representative of any injuries or changes in condition. During the investigation, staff were interviewed and R1's charting notes were reviewed. Based on charting notes, there was no notes that indicated R1 had a fall or a change of condition. According to staff interviewed, they were unaware why R1 was sent to the hospital on 10/13/24 and indicated they did not see or here about R1 having a fall before or on 10/13/24. Additionally staff interviewed also indicated that they did not observe any changes in R1's condition or R1 complaining of pain prior to being sent to the hospital. Based on interviews conducted, interviews conducted and documents reviewed, the department has determined that although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. Report is reviewed with Interim Executive Director and a copy is provided.

On June 18, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit in relation to an incident that occurred on 5/31/25. LPA met with Administrator, Siobhan Surraco and explained the purpose of the visit. The Licensee reported on 5/31/25, the med-tech went to Resident 1's (R1's) room around 7:45pm and R1 reported to the med-tech that he/she took over seven days of medication at one time. R1 told to the med-tech that he/she wanted to hurt himself/herself because he/she was feeling depressed. According to the Licensee, R1 resides in the assisted living community and manages his/her own medications. 911 was immediately called and all required parties were notified. R1 was admitted at the hospital for psychiatric evaluation. During the visit today, LPA interviewed the Administrator, Health Services Director, and Resident Care Coordinator, and reviewed R1's file. R1 was admitted to the facility on 5/21/25 and based on the physician's report dated 5/21/25, R1 was able to manage his/her own prescription and PRN medications and did not show any signs of suicidal ideations. Based on the new physician's report dated 6/11/25 (after incident occurred), R1 has a diagnosis of early onset of Alzheimer's dementia, and is unable to manage his/her own medications. According to staff interviewed, R1 returned back to the community on 6/16/25 and a 1:1 caregiver was implemented throughout the day for 72 hours. Facility staff are conducting status checks. R1 is seeing a psychiatrist and going to behavioral therapy session 5 days a week. Facility is now managing R1's medications and a new reassessment has been conducted. No citations are issued today. Report is reviewed with Administrator and a copy is provided.

On May 15, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit to follow up on an incident that occurred on 5/1/25. LPA met with Administrator, Siobhan Surraco and explained the purpose of the visit. The Licensee reported on 5/1/25 at 2pm, care staff reported that they heard the patio door alarm sounding and noticed that Resident 1 (R1) had exited the secured memory care unit without staff supervision. Staff reported they last saw R1 at around 1:50pm in his/her room. R1 was found a half a block away at around 2:10pm with no injuries and unharmed. During the visit, LPA toured the memory care unit, reviewed R1's file, interviewed the administrator and the Resident Care Director (RCD). Based on medical records dated 11/2024, R1 has mild cognitive impairment (MCI). R1 does not have a history of wandering behaviors based on file reviewed. According to the Administrator, R1 resides at the memory care unit with his/her significant other. R1 left the facility through the memory care outdoor terrace door to the outdoor terrace area and walked to the side of the terrace then left through the second door to get outside the facility. Both doors were observed to be delayed egress doors. Both delayed egress doors were observed to be in functioning condition. According to the administrator and RCD, they are unsure how R1 left without staff noticing but believe that R1 left the facility unassisted during shift change. LPA was unable to interview staff who were present during the incident as they were not present at the facility. Further investigation is required. No citations are issued during the visit. Report is reviewed with Administrator and a copy is provided.

On October 31, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual inspection. LPA met with Administrator, Siobhan Surraco and explained the purpose of the visit. LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a 3 story facility with Memory Care on the first and half of the second floor and Assisted Living on the other half of the second floor and third floor. LPA toured the facility including but not limited to a random sample of resident rooms on each floor, common areas, and kitchen area. LPA observed some residents doing activities with staff or watching television. A comfortable temperature is maintained in the facility and lighting is sufficient for comfort. Hot water temperature measured between 111-119 degrees F throughout the facility. Overall facility was in clean, odor-free and free from any tripping hazards. Resident rooms and bathrooms observed had all required furnishings, and grab bars and built-in non-skid mats in each bathroom. LPA toured kitchen and observed 2 days for perishables and and 7 days non-perishable. Medications, sharps and chemicals were locked and inaccessible to residents. Emergency drill are being conducted and logged every 3 months. Carbon monoxide monitors are working properly. First aid kits were observed present and complete. Five resident records and five staff records were reviewed. Resident records are updated, complete and signed. Staff records are complete, with training logs that have met the basic requirement. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated. The following documents are requested to be submitted to CCL by 11/7/24: -LIC308 Designation of Administrative Responsibility -LIC610E Emergency Disaster Plan -LIC500 Personnel Report No deficiencies are cited at this time. Report is reviewed with Administrator and copy is provided.

Page 2 - LIC9099C Regarding elopements from the facility, LPA cannot determine if this took place based on information received regarding these alleged incidents. There is not enough information and support to show that residents in fact eloped based on staff, video, and family interviews conducted. At the time of the alleged elopements those original staff that were in place, including memory care directors, are no longer present and cannot be contacted. No elopements were reported to management in order to report an incident to the Department. LPA cannot determine if incident reporting took place for the elopements in question. Regarding staff not feeding, dressing, or providing hygiene needs for residents. LPA conducted interviews and made facility observations. Interviews with staff show that the resident in question regarding not feeding or dressing a resident contradict with complainant information and interviews conducted. It was indicated by staff that the residents have the freedom of choice of getting dressed when getting ready in the morning. The resident in question refused to get ready in the morning and staff can not force a resident to change or do something they do not want to do as it will be against their personal rights. For the same resident LPA cannot determine if the was fed on time as the resident was refusing morning care that morning and staff were turned away by the resident and staff intended on returning to the resident to follow up with morning care and feeding. Regarding staff not providing hygiene needs, LPA toured resident rooms that are occupied and observed toilet paper in place. The resident in question is no longer at the facility at the time of investigation to observe if toilet paper was present. Staff interviewed indicate that if there was no toilet paper it would be provided if needed. Staff do replenish toilet paper everyday and when needed. Based on interviews, observations, and other items reviewed, LPA cannot determine if these allegations took place. These allegations are unsubstantiated. Based on these observations, the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time. Report is reviewed with the administrator Siobahn Surraco and a copy of the report is provided.

On 1/10/2024 at 1230pm, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management - other visit in order to deliver an amended complaint report. LPA met with Interim executive director Jessica Pryor and explained the purpose of today's visit. LPA delivered amended findings for complaint #14-AS-20231205135135. LPA is delivering the report as Public as it was marked as Confidential in error. Report is reviewed with interim executive director Jessica Pryor.

On this day, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced required 1 year annual inspection visit. LPA met with interim administrator Eugenia Smith and explained the purpose of today's visit. LPA was allowed entry into the facility and signed in. This is a multi level facility and a memory care building attached. Annual Fees are current upon review. The physical plant was toured inside and outside to ensure the safety of the residents. Patio area outside of memory care building is observed. Fencing and security doors are in good condition and in place. LPA observed the facility kitchen which is clean, in order, and the observed appliances are in good repair. Knives are stored in the kitchen which is not accessible to residents. Cleaning solutions are also locked in multiple janitor closets through out the facility. Perishable and non-perishable food items are observed as in place. LPA observed the medications as in place and locked in med-carts and in med-rooms. First aid kits are observed as complete and placed through out facility including the kitchen. LPA observed that the facility is equipped with full sprinkler system, fire extinguishers are placed through out the facility inspected in October 2023, smoke detectors/carbon monoxide detectors are observed in place, and central heating system is operable. Facility ambient temperature is comfortable for residents and visitors. PPE and additional food supplies are observed as in place. Main laundry room is observed as operational and laundry rooms for use by residents if they choose to wash their own laundry are observed as safe and operational. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Water temperature was measured at 108F in resident rooms in assisted living and memory care. LPA observed several resident rooms at random and all rooms appeared clean, free of odors, and contained all the required furniture per regulatory recommendations. COVID PPE and resident incontinence supplies are observed in place. The facility does not handle resident monies. Staff and resident files are reviewed and observed as current. The facility is in the process of hiring a permanent administrator. Report is reviewed with Eugenia. No citations issued.

On this day, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced post licensing inspection visit. LPA met with interim administrator Eugenia Smith and explained the purpose of today's visit. LPA was allowed entry into the facility and signed in. This is a multi level facility and a memory care building attached. Annual Fees are current upon review. The physical plant was toured inside and outside to ensure the safety of the residents. Patio area outside of memory care building is observed. Fencing and security doors are in good condition and in place. LPA observed the facility kitchen which is clean, in order, and the observed appliances are in good repair. Knives are stored in the kitchen which is not accessible to residents. Cleaning solutions are also locked in multiple janitor closets through out the facility. Perishable and non-perishable food items are observed as in place. LPA observed the medications as in place and locked in med-carts and in med-rooms. First aid kits are observed as complete and placed through out facility including the kitchen. LPA observed that the facility is equipped with full sprinkler system, fire extinguishers are placed through out the facility inspected in October 2023, smoke detectors/carbon monoxide detectors are observed in place, and central heating system is operable. Facility ambient temperature is comfortable for residents and visitors. PPE and additional food supplies are observed as in place. Main laundry room is observed as operational and laundry rooms for use by residents if they choose to wash their own laundry are observed as safe and operational. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Water temperature was measured at 108F in resident rooms in assisted living and memory care. LPA observed several resident rooms at random and all rooms appeared clean, free of odors, and contained all the required furniture per regulatory recommendations. COVID PPE and resident incontinence supplies are observed in place. The facility does not handle resident monies. Staff and resident files are reviewed and observed as current. The facility is in the process of hiring a permanent administrator. Report is reviewed with Eugenia. No citations issued.

On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management - incident investigation visit. LPA met with administrator Megan Leone and explained the purpose of the visit. Also in attendance is the memory care coordinator Bernadette King. LPA discussed the incident that occurred with R1 was unseen and the circumstances are unclear of what actually transpired in terms of a possible fall that may have occurred on 08/15/2023. The facility is within the required reporting time frame to licensing of the incident and the facility is in the process of submitting an incident reporting to the Department. Responsible parties are to be notified on this day according to the administrator. No citations issued on this day.