Harborview Senior Assisted Living.

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA Domingo was welcomed by, identified herself to, and discussed the purpose of the visit with Genoveva Guerrero, Manager. The facility serves thirty (30) elderly residents; ages 60 years and above; all of whom may be non-ambulatory and five (5) of which may be bedridden. there were a total of twenty five (25) clients in care, and per medical records, all were ambulatory. LPA, accompanied by the house manager, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities.  Call box was available in each resident unit and were tested for functionality. Resident's room temperatures were within a comfortable range. The facility’s ambient internal temperature was 70 F. Hot water temperature at taps accessible to clients were all compliant: Kitchen sink was 115 F, Bathroom #1 sink was 115 F, and Bathroom #2 sink was 118 F. Refrigerator temperature was 34 F and freezer temperature was -0 F. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. [CONTINUED ON LIC 809C] 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 [CONTINUED FROM LIC 809] The fountain structure is not accessible to residents or visitors without staff accompaniment and there is a locked fenced area around the structure. Per the licensee's staff, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. The last disaster drill was conducted in 2/2/26. LPAs interviewed multiple staff and clients. LPA reviewed multiple staff and client records/files. The interviews did not raise any significant licensing concerns. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. The reviewed files contained required documents. Confidential records were stored in locked areas. Licensee's staff also presented proof of current/active business liability insurance and surety bond. No deficiencies were observed or cited during today's annual inspection . An exit interview was conducted with Genoveva Guerrero, Manager to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

...Continued from 9099 and staff from St. Paul’s PACE provided nursing support to monitor her condition. According to S1, R1 disliked the colostomy bag and would occasionally pull on the tubing, causing leaks and soiling her clothing and bedding. R1 was no longer able to use the toilet independently and began wearing adult diapers (Depends) to prevent accidents. Shortly after R1 began using Depends, staff observed a rash developing around her vaginal area. During the interview, R1 did not report any concerns regarding staff or her own well-being. Facility staff and PACE nursing staff continued to monitor her condition. Based on the information available, there is insufficient evidence to conclude that the blisters or rash in R1’s vaginal area were the result of sexual abuse. On the allegation: Resident sustained unexplained injury while in care. Interviews and documentation indicate that the blisters observed on R1 were identified by facility staff and promptly reported to the PACE nursing team and W2. Following recent surgery, R1 returned to the facility with a new colostomy bag. According to S1, R1 often expressed discomfort with the colostomy bag and would occasionally pull on the tubing, causing leaks that contributed to skin irritation and the development of blisters. Facility staff and PACE nursing staff monitored R1’s condition. Based on the information obtained, there is insufficient evidence to conclude that R1’s injuries were the result of abuse or 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 did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided via email.

Licensing Program Analyst (LPA) Janet Ngallo conducted an unannounced Case Management Visit.  LPA was greeted by and met with Compliance Staff Gladys Vincent, to discuss the purpose of the visit.  Facility Manager Genoveva Guerrero later joined the visit. Today's visit is in response to the self-reported death of Resident 1 (R1).  R1 passed away on 11/17/2025. LPA conducted a wellness check at the facility and collected records for review; no health or safety issues were identified.  No deficiencies were cited or observed on this date. An exit interview was conducted with Facility Manager Genoveva Guerrero who was provided with a copy of this report and Appeal Rights (LIC9056 03/22).  Their signature confirms receipt of these documents.

S1 and S2 stated R1 was a very complicated resident. S1 stated R1 always said he/she had to leave the facility to go with R1s son and when staff would try and redirect R1, R1 would become upset and hit staff with a cane and say mean things to them in Spanish. S2 stated staff had to rotate constantly when dealing with R1 because they noticed R1 would become a bit calmer when R1 would see a new face and didn’t like dealing with the same staff member the whole day. On 02/06/2024, S1 was working his/her shift as a MedTech and preparing medications to pass out when S1 saw R1 walking toward the front door. S1 told R1 to not go outside, and R1 proceeded to walk out the front door acting like R1 didn’t hear what S1 said. S1 went after R1 but before doing so S1 needed to secure the medication cart and lock it before going outside. S1 said when R1 finally went out the front door, S1 told R1 to come inside, and R1 turned around and began swinging his/her cane toward S1. S1 said as R1 was swinging the cane facing S1, R1 was also walking backwards and suddenly R1 tripped over R1s own feet and fell to the floor landing on his/her left arm. S1 said she did a head-to-toe assessment on R1 and also called for help over the radio. S1 said R1 said he/she had no pain on his/her body or legs. S1 mentioned that S2 arrived and they helped R1 up onto a patio chair and that’s when R1 started complaining of wrist pain and S1 called S4 to come. S1 told me once S4 came, S4 decided to call 911 to get R1’s injuries further checked out and medics arrived and transported R1 to the hospital where R1 was later diagnosed with a fractured left wrist. S3 and S5, stated the complaint received about R1 eloping outside the facility is false. S5 stated the facility has a secure perimeter and staff knew R1’s whereabouts the whole time leading up to his/her fall. S3 added there are no rocks large enough to climb on facility grounds and there were no rocks near where R1 had a fall. Based on photos obtained, the facility has a facility fence preventing residents to go out of the facility without assistance. There were no rock formations that would make the residents climb and cause injury. Based on records review, according to resident appraisal dated 2/1/2024, R1 is able to ambulate with the help of a cane. page 2 of 3 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 For the allegation of Staff did not provide resident’s records to resident’s authorized representative, RP stated that a family member (F1) has requested information from the facility administrator and believes they are withholding information. In addition, F1 requested to view camera footage but was told that the cameras were not operational and is not being given full disclosure of the incident or full access to R1’s files. According to S3, on the day of R1s accident as well as the times F1 went to the facility, F1 asked how the incident occurred and each time F1 was told how R1 fell, and staff never avoided telling F1 anything. S3 stated no information was withheld from F1 and they had no reason to lie to F1 or not tell him/her what occurred. S3 said F1 asked for video surveillance of the incident, and they told him/her they didn’t have any footage of the fall because their cameras don’t record and are only live cameras. S3 said F1 never came to the facility asking for R1s admission agreement and if F1 did, they would have no problem giving it. S3 said a copy was provided to F1 at the beginning. S1 also added that days after the incident F1 came to the facility to collect R1s belongings and F1 had asked for a copy of R1s contract. S1 said at the time S3 and S4 were not at the facility and advised F1 that S1 couldn’t get a copy at the moment but if F1 came back when the managers were present, they will gladly provide that to F1. S1 said he/she even mentioned emailing or giving S4 a call regarding the contract and maybe S4 would be able to email it over. There were several attempts to contact RP and F1 but never received a response. Based on interviews, records review and observations, the department has determined that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Report is reviewed and a copy is provided. page 3 of 3

Licensing Program Analyst (LPA) Daniel Pena conducted an unannounced case management visit to follow-up on consultation provided during a required annual inspection on May 15, 2024. After identifying himself and explaining the reason for the visit, LPA was allowed into the facility. LPA met with Gladys Vincent, Compliance Analyst. During the visit, LPA toured the facility, inside and out, reviewed records and interacted with residents in care. No deficiencies were cited. An exit interview was conducted with Ms. Vincent. A copy of this report and Licensee Rights (LIC 9058/16) were provided to Ms. Vincent, and her signature on this form confirms receipt of the documents.

Daniel Pena, Licensing Program Analyst (LPA) conducted an unannounced annual one year required inspection. LPA was greeted by Office Assistant, Gladys Vincent. LPA later met with Jeffery Settineri, Administrator and Genoveva Guerrero, Facility Manager. LPA introduced himself, explained the purpose of the inspection, and was allowed entry into the facility. Facility census was twenty-five (25) residents. The facility serves thirty (30) elderly residents; ages 60 years and above; all of whom may be non-ambulatory and five (5) of which may be bedridden. A tour of the facility was conducted inside and out. LPA, accompanied by Mr. Settineri and Ms. Guerrero, conducted a general overall inspection, which included, but was not limited to the following: physical plant, food service, facility administration, medication management, resident and staff records, resident rights, and activities. During today's inspection LPA observed the following: All indoor and outdoor passageways were free from obstructions. All bodies of water were observed to be in compliance with Title 22 regulations. Per Mr. Settineri, there are no firearms or other dangerous weapons stored in the facility. Facility layout is consistent with the Fire Clearance. LPA toured a sample of resident rooms and all had a bed, night stand, dressers, chairs and sufficient lighting available for residents. Licensee provided each resident with clean linen in good repair. All resident rooms had an operating signal system and individual pendants for resident use. The hot water temperature used by residents of the facility were measured to be within Title 22 regulation requirements. The facility had multiple functioning carbon monoxide detectors that met statutory requirements. The facility also had operating smoke detectors that met statutory regulations along with several operable fire extinguishers. The facility was stocked with a two day supply of perishable and seven day supply of nonperishable food items. The kitchen and dining areas were clean, in good repair, and there were no 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 observable expired food items. Per Ms. Guerrero, the last fire drill was conducted on May 14, 2024. LPA was able to verify that physical medications in bubble packs and medication containers were being administered by physician's orders. LPA reviewed staff records and verified that all staff reviewed have the required Personnel Record, Criminal Record Clearance, TB clearance, Health Screening Report, and required training in their file. LPA reviewed resident records and verified that a current Physicians Report, Identification and Emergency Information, Admission Agreement, and Centrally Stored Medication and Destruction Record were in each resident's file. LPA conducted a sample of staff interviews which did not raise licensing concerns. Based on today's inspection, no deficiencies were observed. An exit interview was conducted, and a copy of this report was provided to Administrator Settineri. Administrator Settineri was provided a copy of their Licensee/Appeal Rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights.

Staff 1 (S1) arrived at the area and separated R1 and R2 and documented the event on an Incident Report. R1 complained of pain the next day but it subsided later that evening. Staff interviews indicated R1 received a fingerprint size bruise on their shoulder. The residents and others in the area were contacted for their observation. Most of the residents contacted had Dementia diagnoses and were unable to provide statements. R1 provided their account which is consistent with the allegation reported to CCLD. R2 provided a statement saying they were sorry for striking R1. R3 was interviewed and said they did not see the incident. When asked, R3 said they never witnessed any resident strike another resident during the time they lived at the facility. LPA contacted an outside agency regarding the incident. LPA asked the outside source if they observed concerns with a lack of supervision at the facility. The outside source reviewed their records and found no complaints or related visits regarding a lack of supervision. Records were reviewed, including staffing schedules. LPA found no evidence of staff shortages. Per Staff 2’s (S2) interview and staffing level record review, there were three staff working on the day of the incident. S2 said the shift was fully staffed. S2 conducted a post-action review of the incident and did not identify lack of supervision as a contributing factor. Per S2, S1 was in the dining area at the time of the incident. S2 said the altercation happened quick but S1 was able to respond and address it immediately. LPA asked S2 about the Incident Report submitted to CCLD. The report referenced counseling was provided. S2 said the term counseling referred to communication/training regarding R2’s updated care plan was disseminated to all staff. S2 said R2’s care plan was modified in response to R2’s change in behavior. LPA interviewed S1. S1 said they were in the area when the incident occurred. S1 witnessed R2 squeeze the area of R1’s arm. S1 observed no immediate markings but said a bruise appeared on R1, 2-3 days later. S1 was in the kitchen when they heard R1 yell. S1 responded to the scene immediately and redirected the two residents. S1 said they asked residents in the area what they observed but none of the residents reported seeing anything. S1 said neither resident required one-on-one supervision or had a history of aggressive behavior. S1 prepared the LIC624 report documenting the incident. The Department has investigated the allegation that lack of supervision resulted in resident-on-resident abuse. Based upon interviews with residents, staff, and outside sources, no corroboration or information was obtained to support the allegation. No evidence was obtained to prove the incident occurred due to a lapse in supervision by staff. The Preponderance of Evidence standard was not met. 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 An exit interview was conducted with Ms. Guerrero and a copy of this report was provided to Ms. Guerrero whose signature below confirms receipt of copies of this report and Licensee Rights (LIC 9058).