Bayshire San Dimas.

The investigation revealed the following: regarding the allegation “Unqualified staff member is providing care to residents in care.” It is alleged an unqualified staff member is providing wound care to residents. Five (5) out of the five (5) staff interviewed denied this allegation. Four (4) out of the four (4) residents interviewed did not corroborate this allegation. Review of staff rosters revealed that two staff members have the same first name but hold different titles. Records reviewed revealed that S1 is a Licensed Vocational Nurse and S5 is a Medication Technician. Resident interviews revealed that residents feel well cared for by staff and feel staff meet their care needs. Staff interviews revealed that S1 holds a current Licensed Vocational Nurse (LVN) license with an expiration 12/2027 and S5 has received training on medication administration and other topics associated to their position. Interview with S2 revealed that S1 is qualified to provide wound care. During record review, LPA Ramirez observed S1’s valid Licensed Vocational Nurse license and S5’s recent Medication Technician training. Review of R1-R4 resident files revealed that they receive wound care from an outside agency and these outside agencies document the care provided. 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 during this visit. Exit interview was conducted. A copy of this report was provided.

The investigation revealed the following: regarding the allegation “Unqualified staff member is providing care to residents in care.” It is alleged an unqualified staff member is providing care to residents. Five (5) out of the five (5) staff interviewed denied this allegation. Four (4) out of the four (4) residents interviewed denied this allegation. Resident interviews revealed that residents feel well cared for by staff and feel staff meet their care needs. Staff interviews revealed that S1 holds a current Licensed Vocational Nurse (LVN) license with an expiration 12/2027 and S5 completed training on according to their position. During record review, LPA Ramirez observed S1’s LVN license and S5’s recent training. 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 during this visit. Exit interview was conducted. A copy of this report was provided.

R1 wandered from the facility. Based on LPA’s observations and interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. It should be noted no deficiency issued at today's visit. Prior investigation on 09/30/2024 and 10/3/24 LPA Pena Substantiated and issued deficiency. In regards to the allegation Due to lack of supervision, resident eloped, the complaint findings dated 12/10/2024 were previously addressed with Substantiated findings by LPA Pena. It notes the following that S1 stated that what she thinks happened was that R1 went out the back gate and the alarm did not go off. S1 showed LPA how the back gate’s alarm work and it involved 4 steps to secure the gate. S1 indicated that someone must have missed a step or two in locking it, hence the alarm failed to go off. LPA observed that the back gate leads to a driveway towards the main road next to the freeway. The facility rosters dated 10/03/2024 specified a total of 19 memory care residents including R1, 7 caregivers and 3 med techs assigned on different shifts in the memory care unit. However, when R1 wandered away from the facility on 9/30/2024, there were only (2) caregivers and (1) med tech working. Therefore, there was sufficient evidence to corroborate the allegation of lack of supervision which led to R1 wandered from the facility. Based on LPA’s observations and interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . It should be noted no deficiency issued at today's visit. Prior investigation on 09/30/2024 and 10/3/24 LPA Pena Substantiated and issued deficiency. 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 was immediate. Staff stated that once the pull cord is pulled it will go to any staff who has a pager. Pager gives the location. Interview with Resident R1 who stated that the pull cord is working and staff always assist right away. Resident's R2-R9 stated the pull cord is working well and response time is quick. It should also be noted that findings were delivered 05/13/2025 for Staff do not answer resident's calls for assistance timely. This allegation was 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 . In regards to the allegation Staff did not ensure leaks were fixed timely, based on facility tour, interviews and information gathered it was observed by the LPA tour on the initial visit 11/26/2024 that there were no leaks. Interview with Health Services Coordinator Laura Sanchez who stated that. any leak is fixed right away. Staff S2 stated that any leaks are fixed within the hour and said they hadn't had one in awhile. Interview with Staff S3 who is Maintenance Director who stated that there are no leaks he is aware of and if there was you would see them now. Interview with Resident's R1- R 9 who all stated they didn't observe any leaks. 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 Residents have unexplained bruises based on interviews conducted and information gathered Resident's R1- R9 all stated they do not have unexplained bruises and have not seen anyone with Unexplained bruises. Also stated that staff have not told them to cover up bruises. Staff stated that they had not covered up residents bruising. Said if skin tear they may wear a hospital protective sleeve, but never anything malicious. 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 are not reporting incidents to authorized representatives, based on interviews conducted and information gathered it was revealed by Health Services Coordinator Laura Sanchez that all incidents are always reported to Licensing. Special Incident Reports (SIR's) were submitted 09/30/2024 and 12/01/2024 both concerning the elopement of 2 residents. Incident reported 09/30/2025 states that resident was located by Highway Patrol off of the 57 entrance. 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 were able to bring the resident back. On the 12/01/2025 report the resident was across the street walking on the sidewalk and walking back to the facility. 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 do not safeguard residents personal property, based on interviews conducted and information gathered Resident's R1- R9 all stated they have never had any items stolen from their rooms. Said housekeeping does a good job. All stated staff are nice and helpful. Staff stated that Resident R1 or family never reported any items missing and they have a Personal Inventory List to ensure documentation of all resident's belongings. 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 .

Allegation: Facility staff are not properly turning resident resulting in pressure injury. The complaint alleges that staff are not moving Memory Care Unit resident (R1) often, and as a result in mid August 2025 the resident developed a new pressure injury on the resident's bottom/coccyx area. It was reported that R1 has past history of pressure injuries, with the most recent pressure injury being in their heel and toe. A total of 7 staff were interviewed, of which all denied the allegation. None of the residents interviewed acknowledged the allegation. Staff interviews revealed that in mid-August 2025 a caregiver reported to the Memory Care Unit lead staff/med-tech that R1 had redness and a small opening in the bottom area, whom then contacted primary care providers and family. Per document review, on August 20, 2025 a SCAN Nurse Practioner submitted a home health referral order for wound care services of the toe and coccyx skin breakdown. Picture evidence was obtained. The picture depicts redness with slight skin abrasion located in R1's bottom. Records indicate R1 is dependent for all ADL's due to advanced Dementia. According to staff, repositioning procedures have been followed and there is currently no pressure injury in R1's bottom. During today's visit, the SCAN Nurse Practioner was on-site; therefore LPA requested they conduct a full body assessment to determine if there is a pressure injury in the bottom/coccyx area. The nurse reported back to LPA that there is no redness or open wound to the coccyx and bottom area. There is insufficient evidence to support the allegation. Allegation: Facility staff are leaving resident in bed for extended periods of time. It is alleged that on September 24, 2025, at approximately 6:30 PM, resident (R1) was observed in their bed with a napkin with crumbs on the resident's chest, indicating the resident was fed dinner in their bed instead of being wheeled to the dining room in the resident's Geri chair. Memory Care Unit residents stated they are not left in bed for extended periods of time and are checked on frequently. According to staff interviews, caregiver staff are responsible for getting R1 up in the morning, transferring them to their Geri chair, taking the resident to the dining room for breakfast meal, and then to the activities room. Staff stated that R1 is typically put to bed for a nap after lunch time, and then transferred to their Geri chair prior to dinner meal time in the Memory Care Unit dining room. Staff interviews revealed that on 9/24/25, R1 was taken to their room for a nap after lunch. PM caregiver staff used the Hoyer lift on R1 at approximately 3 PM, and noticed that the resident's right outer bottom cheek had redness and the resident was sound asleep. The caregiver decided to keep the resident in bed because they thought the redness may have been a result of Geri chair use earlier in the day. According to the PM staff (S1) the resident was fed dinner in their room that day, continued checks and repositioning was performed, there was no neglect, and it was an isolated incident. Per document review, the Physician's Report states R1 is bedridden due to both physical and mental condition, spends all day either in bed or Geri chair and requires 2-person assist transfers are required with use of Hoyer lift. Therefore, the allegation cannot be supported. 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 . Exit interview and a copy of the report was issued to Health & Wellness Director Laura Garcia.

The investigation revealed the following: Regarding: Licensee does not ensure that facility is kept in good repair. It is alleged that there is a water leak in the kitchen ceiling and that the facility’s plumbing is in disrepair. During interviews, (5) staff denied the allegation. Five (5) interviewed staff indicated that the facility does not have a water leak in the kitchen nor anywhere else in the facility. S1-S3 stated that several weeks ago, the facility had water dripping from the dining and activity room ceiling in the Memory Care section of the building due to condensation building up in the drain pan of the air conditioning unit. However, interview with Plant Operations Director (S3) indicated, leak has been resolved. S3 stated, air conditioning unit was set at a lower temperature than usual and consequently, made the unit accumulate a high quantity of condensation which dripped from the drip pan and on to the ceiling tiles and floor in the dining and activity rooms. S3 stated, condensation accumulation is more common in times of high heat because the AC unit works harder to maintain a cool temperature. S3 further stated, “The water leak from the ceiling had nothing to do with the facility’s plumbing.” S3 indicated, in this facility, plumbing is nested along the inside of the walls and under the flooring and plumbing does not run above the ceiling. S1- S3 stated, no plumbing issues have been observed or reported. S1-S6 further indicated, they have not observed any more water leaking from the ceiling in the dining and activity rooms nor anywhere else in the facility. Interviews with (6) out of (6) residents have no concerns regarding water leaks. During LPA inspection of the physical plant, no water leaks were observed. Staff and resident interviews, and LPA observations do not corroborate the allegation. Regarding: Staff do not ensure that residents' rooms are maintained in a sanitary condition. It is alleged that blood, vomit and feces soaked garments are frequently placed in residents’ dirty clothes baskets which remain there for (7) days or more. During the visit, (8) out of (8) staff interviewed deny the allegation. Staff interviewed indicated that heavily soiled bedding, towels and clothing which may contain vomit, feces or blood, are never mixed with residents’ mildly soiled articles which are placed in their laundry baskets in their room. Staff further indicated, if linen or clothing become heavily soiled, items are removed immediately out of residents’ rooms and placed in bags and tied up to prevent fluids from transferring onto other surfaces. ***Continues on LIC 9099-C page 2 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 The bags are stored temporarily in the (2) soiled linen closets from which caregivers and housekeeping staff collect to wash. Bags collected are never kept for more than 24 hours before they are washed. Staff further stated, the facility has a laundry schedule for the AM, PM and NOC shifts which are followed to ensure residents’ linen and clothes are washed in a timely manner. Six (6) staff indicated, the facility has three laundry rooms equipped with commercial and industrial grade washers and dryers which accommodate large quantities of soiled items. Staff further indicated, laundry hampers in resident rooms are always monitored by caregivers and housekeeping staff and “emergency washes” are conducted in between scheduled laundry times particularly for items which should not remain in residents’ rooms to prevent contamination and odors from transferring. During the inspection of 10 resident rooms, no blood, vomit and feces soaked garments were observed in resident laundry baskets nor anywhere else in their room. Interviews with (6) out of (6) residents indicated their clothing gets washed in a timely manner and they have no concerns with clothes or linen not being collected or properly removed from their room to be washed. Review of laundry schedule indicated washing is conducted daily for every shift. At the time of visit, LPA observed laundry attendants washing clothes and linen. Staff and resident interviews, observation and record review, do not corroborate the allegation. 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 Stephanie Guerrero, Wellness Nurse, and a copy of this report was provided.

was immediate. Staff stated that once the pull cord is pulled it will go to any staff who has a pager. Pager gives the location. Interview with Resident R1 who stated that the pull cord is working and staff always assist right away. Resident's R2-R9 stated the pull cord is working well and response time is quick. It should also be noted that findings were delivered 05/13/2025 for Staff do not answer resident's calls for assistance timely. This allegation was 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 . In regards to the allegation Staff did not ensure leaks were fixed timely, based on facility tour, interviews and information gathered it was observed by the LPA tour on the initial visit 11/26/2024 that there were no leaks. Interview with Health Services Coordinator Laura Sanchez who stated that. any leak is fixed right away. Staff S2 stated that any leaks are fixed within the hour and said they hadn't had one in awhile. Interview with Staff S3 who is Maintenance Director who stated that there are no leaks he is aware of and if there was you would see them now. Interview with Resident's R1- R 9 who all stated they didn't observe any leaks. 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 ensure alarmed exit doors work properly at all times, the complaint findings dated 12/10/2024 were previously addressed with Substantiated findings by LPA Pena. COMPLAINT CONTROL NUMBER: 28-AS-20241001133551 . It notes that S1 stated that what she thinks happened was that R1 went out the back gate and the alarm did not go off. S1 showed LPA how the back gate’s alarm work and it involved 4 steps to secure the gate. S1 indicated that someone must have missed a step or two in locking it, hence the alarm failed to go off. LPA observed that the back gate leads to a driveway towards the main road next to the freeway. The facility rosters dated 10/03/2024 specified a total of 19 memory care residents including R1, 7 caregivers and 3 med techs assigned on different shifts in the memory care unit. However, when R1 wandered away from the facility on 9/30/2024, there were only (2) caregivers and (1) med tech working. Therefore, there was sufficient evidence to corroborate the allegation of lack of supervision which led to R1 wandered from the facility. Based on LPA’s observations and interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . It should be noted no deficiency issued at today's visit. Prior investigation on 09/30/2024 and 10/3/24 LPA Pena Substantiated and issued deficiency. In regards to the allegation Residents have unexplained bruises based on interviews conducted and information gathered Resident's R1- R9 all stated they do not have unexplained bruises and have not seen anyone with Unexplained bruises. Also stated that staff have not told them to cover up bruises. Staff stated that they had not covered up residents bruising. Said if skin tear they may wear a hospital protective sleeve, but never anything malicious. 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 . 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 to the allegation Due to lack of supervision, resident eloped, the complaint findings dated 12/10/2024 were previously addressed with Substantiated findings by LPA Pena. It notes the following that S1 stated that what she thinks happened was that R1 went out the back gate and the alarm did not go off. S1 showed LPA how the back gate’s alarm work and it involved 4 steps to secure the gate. S1 indicated that someone must have missed a step or two in locking it, hence the alarm failed to go off. LPA observed that the back gate leads to a driveway towards the main road next to the freeway. The facility rosters dated 10/03/2024 specified a total of 19 memory care residents including R1, 7 caregivers and 3 med techs assigned on different shifts in the memory care unit. However, when R1 wandered away from the facility on 9/30/2024, there were only (2) caregivers and (1) med tech working. Therefore, there was sufficient evidence to corroborate the allegation of lack of supervision which led to R1 wandered from the facility. Based on LPA’s observations and interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . It should be noted no deficiency issued at today's visit. Prior investigation on 09/30/2024 and 10/3/24 LPA Pena Substantiated and issued deficiency. In regards to the allegation Staff are not reporting incidents to authorized representatives, based on interviews conducted and information gathered it was revealed by Health Services Coordinator Laura Sanchez that all incidents are always reported to Licensing. Special Incident Reports (SIR's) were submitted 09/30/2024 and 12/01/2024 both concerning the elopement of 2 residents. Incident reported 09/30/2025 states that resident was located by Highway Patrol off of the 57 entrance. Staff were able to bring the resident back. On the 12/01/2025 report the resident was across the street walking on the sidewalk and walking back to the facility. 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 do not safeguard residents personal property, based on interviews conducted and information gathered Resident's R1- R9 all stated they have never had any items stolen from their rooms. Said housekeeping does a good job. All stated staff are nice and helpful. Staff stated that Resident R1 or family never reported any items missing and they have a Personal Inventory List to ensure documentation of all resident's belongings. 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 .

Interviews with residents revealed 3 out of 8 residents interviewed were not aware with process as their responsible party assisted with choosing a hospice agency. 3 out of 8 residents were unable to be interviewed due to cognitive skills. 2 out of 8 residents stated they did not know they had a choice in picking the hospice service agency. Interviews conducted with staff revealed some residents are admitted to the facility with their hospice agency in place. However, when the residents residing are assessed and need to obtain hospice care, the Health - Wellness Director meets with the responsible party and provides recommendations of different hospice agencies from which responsible parties or residents choose. Three of the responsible parties interviewed belief there was only one hospice service agency and were not aware there were other hospice agencies to choose from. One of the responsible parties interviewed stated they were aware they had different choices for hospice care. Documents reviewed revealed there are 27 residents currently in hospice and 8 different hospice agencies providing services to residents in care. A total of 7 death reports were reviewed, 4 different hospice agencies were noted providing care at the time of death for the seven 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 . Exit interview was conducted with Laura Sanchez Health-Wellness Director and a copy of this report was provided.

Documentation from J & N Duct Cleaning dated 09/10/2024 was submitted. In regards to the allegation Staff do not answer resident's calls for assistance timely, based on interviews conducted, information gathered and tour of the facility it was revealed during inspection of rooms 161, 180, 186 ,192 , 233, 236, 238, 364 and 368 pull cord was initiated by LPA and staff responded within 5 to 10 minutes. Staff stated pendant is monitored at reception and staff will respond quickly. Stated that certain times of day are more busy than others and they have new pagers and have a plan to respond quickly. 5 of 7 residents interviewed stated that they used the pull cord for assistance and staff came quickly to assist. The other 2 residents stated they have not needed any assistance and are independent. 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 do not dispose of soiled diapers properly based on interviews conducted, information gathered and facility tour it was revealed that all rooms inspected there were no bad smell or odors and no soiled diapers in the bathroom. Staff stated that there has been no complaints and they are really good about that. 3 of 7 residents stated they have had assistance with diaper changes and it has gone well and there has not been any soiled diapers left in the room. 4 residents changed their own diaper. 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 Licensee does not ensure sufficient training is provided to staff in the facility, based on interviews conducted and information gathered staff stated that they have an in-service every month and additional training's. Facility submitted staff training documentation covering 08/2024-10/2024. Training contained employee signatures of those who had attended. Topics covered were schedule guideline reminders 08/25/24, Med Tech refresher 09/04/2024, Pendant Response/Call Log 09/09/2024, Safety and Proper Body Mechanics 09/25/2024, Proper Transfer Mechanics 10/08/2024, and Elopements 10/09/2024. 7 of 7 residents stated they feel staff have been trained and that they are efficient and professional. 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 does not ensure emergency evacuation drills are conducted at the facility for residents in care, staff stated that drills are done every month and also additional training's. 5 of 7 residents stated that evacuation drills have been conducted. 2 residents were unsure. Facility submitted Fire Drill Report conducted by Southwest Fire and Safety which included order of evacuation drill. Log of those who had attended was submitted for the following dates:08/25/2024, 09/14/2024 and 04/16/2025. 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 does not ensure facility is kept free of dust on surfaces, based on interviews conducted and information gathered it was revealed on tour of the facility and resident rooms by the LPA that 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 rooms were clean and there was no dust observed on the surfaces. Staff stated that housekeeping is here every day and in every unit. 7 of 7 residents stated that staff does a great job keeping the facility and rooms clean and they have not observed any dust on surfaces. Documentation of monthly A/C and heating dated 04/03/24- 09/03/24 was submitted in which a/c and heating are checked monthly and filter changed monthly. Documentation from J & N Duct Cleaning dated 09/10/2024 was submitted in which the air ducts are taken care of in the building. 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 does not ensure window screens are in good repair, based on interviews conducted, information gathered and tour of resident rooms it was revealed during inspection of resident rooms 161, 180, 186, 192, 233, 236, 238, 364 and 368 that all screens were in good repair. Resident's R1-R7 all stated that the screens in their rooms are all in good condition. Staff stated that all screens are in good repair and that maintenance is on site to fix things right away. 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 do not ensure reporting requirements are being followed, based on interviews conducted and information gathered staff stated that Special Incident Reports (SIR's) are always completed and submitted to licensing promptly. Facility submitted Special Incident Reports (SIR's) covering September 2024- November 2024 to LPA. LPA verified the reports which included 2 residents SIR reports 09/12/2024, SIR 09/14/2024, SIR 09/15/2024, Notification of Hospice Services 2 resident's 09/28/2024, and 09/30/2024 Death Report 09/30/2024. In October Death Report 10/06/2024, SIR 10/17/2024, Death Report 10/21/2024, SIR 10/23/2024, Notification of Hospice Services 10/24/2024, 2 SIR's 10/26 and Death Report 10/31/2024. In November Notification of Hospice Services 11/01/2024, SIR 11/02/2024, Death Report 11/03/2024, SIR 11/03/2024, Death Report 11/04/2024, SIR 11/07/2024, SIR 11/13/2024, Notification of Hospice Services 11/13/2024 and SIR 11/23/2024 and 2 Death Reports 11/23/2024. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did no t occur, therefore the allegation is UNSUBSTANTIATED. In regards to the allegation Staff does not ensure chemicals are made inaccessible to residents, based on interviews conducted, information gathered and tour of resident rooms it was revealed during inspection of resident rooms 161, 180, 186, 192, 233, 236, 238, 364 and 368 that there were no chemicals accessible to residents in their rooms. Resident's 1-7 all stated there are no chemicals in their rooms and nothing poisonous. Staff stated that all chemicals are locked up. 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. 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 to the allegation Staff does not ensure sharp objects are made inaccessible to residents, based on interviews conducted, information gathered and tour of resident rooms it was revealed during inspection of resident rooms 161, 180, 186, 192, 233, 236, 238, 364 and 368 that there were no sharp objects accessible to residents in their rooms. Resident's 1-7 all stated that there are no sharp objects in their rooms. Staff stated that any sharp objects are kept in an appropriate place away from residents. 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 do not ensure proper hand hygiene is performed while providing care for residents 7 of 7 residents stated that staff do have proper hand hygiene and wear gloves when serving food and administering medication. Staff stated that they use universal precautions and wash their hands after resident care. 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.

The investigation revealed the following. Regarding Allegation(s) : Staff neglect resulted in a resident's death – It is alleged facility staff neglected R1 which resulted in R1’s death. Review of R1’s resident records revealed R1 was admitted into the facility on 06/21/2023 and was self-responsible. R1 was transferred from another hospice care provider on 11/04/2024 and new hospice care orders were placed. On 11/05/2024, during hospice care visit, hospice care staff documented R1 requested that medication ordered on 11/04/2024, not be ordered and administered unless “absolutely necessary”. On 11/05/2024, R1’s physician ordered R1 discontinue the use of Morphine Sulfate 10mg/0.5 ml- every 4 hours as needed, Lorazepam 1mg/0.5m- every 6 hours as needed, Morphine Sulfate 20mg/1ml- every 4 hours as needed, Morphine Sulfate 5mg/0.25ml- every 4 hours as needed, Lorazepam 1 tab- every 4 hours as needed. Review of R1’s hospice care notes and facility care notes revealed hospice staff and facility staff regularly documented R1’s care and supervision. Review of R1’s death certificate did not corroborate above allegation. Four (4) out of the four (4) staff interviewed denied above allegation. Four (4) out of the four (4) residents interviewed denied above allegation. R1 was not available for interview. Interview with R1’s family did not corroborate this 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 . Staff had unauthorized access to a resident's personal funds- It is alleged facility staff were monitoring R1’s financial situation. Review of R1’s resident records revealed R1 was admitted into the facility on 06/21/2023 and was self-responsible. Four (4) out of the four (4) staff interviewed denied above allegation. Four (4) out of the four (4) residents interviewed denied above allegation. Interview with R1’s family did not corroborate this allegation. Review of R1’s facility record, including payments made to the facility for services, did not corroborate above 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 . No deficiencies were cited during this complaint investigation visit. Exit interview was conducted. A copy of this report was provided via email.

An Informal Conference meeting was held at Monterey Park Adult and Senior Care Regional Office. Present during this meeting were License Program Manager (LPM) Fernando Fierros and License Program Analysts (LPAs) Blanca Gonzalez, Jose Villalobos, and Luis De Leon. The following representatives were present from Bayshire San Dimas: Operation Manager Tanner Peterson, Director of Operations Chad Coleman, and Health Services Director Laura Sanchez. The Informal Conference was conducted to discuss the oversight of the facility, specifically to address the number of complaints received since the facility was licensed and Title 22 violations, administrator hours and hospice waiver increase requests. The following topics were discussed: · Hospice Waiver Increase request from 30 to 38. Health Director Laura Sanchez provided a copy of the Hospice letter Increase from twenty (20) to thirty (30) hospice residents. · Title 22 regulations regarding administrator qualifications and administrator to be on site sufficient number of hours to permit adequate attention to the management and administration of the facility. · LIC-308 Designation of Facility Responsibility - Administrator to declare a responsible staff for each shift that meets qualification in the absence of the Administrator. · LIC 500 - Staff Schedule to contain administrator hours and be available to the department as needed. · High Volume of complaints for the facility and that the Administrator is to provide oversight regarding staff training and resident concerns. · Licensee Annual Fees · Bedridden Plan See Continuation Page 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 The following documents were requested: Updated Hospice Waiver Increase Request that includes statements that comply with Title 22 regulations for Section 87632 Hospice Care Waiver. Hospice Waiver Increase request letter signed by the licensee. LIC 500 Personnel Record which indicates the current staff schedule and includes the administrator schedule. During meeting Administrator agrees to the following: Provide an updated staff schedule upon the department’s request. Submit an updated LIC-308 Designation of Facility Responsibility to department that covers each shift. Operation Manager and Director explained internal procedures to mitigate the number of complaints. LPM Fierros discussed the number of citations issued to the facility from the date the license was issued to the current date and provided the Administrator with copies of Title 22 regulations for which facility had been cited. A copy of POC's were provide to Administrator. The following regulations were reviewed. 87468.1 Personal Rights of Residents in All Facilities 87405 Administrator - Qualifications and Duties 87355 Criminal Record Clearance 85707 Admission Agreement 87411 Personal Requirements 87303 Maintenance & Operation 87705 Care of Persons with Dementia 87309 Storage Space Exit interview was conducted and a copy of the report was provided to Administrator Chad Coleman.

During interviews with the residents, none of them corroborated the allegation. LPA interviewed four (4) different residents whose family members and friends participate in the family council, and they all stated that their families have not been prevented from participating in the family council. During interviews with staff, none of them corroborated the allegation. One staff member interviewed stated that they do permit the resident council to hold meetings at the facility, and they recently had one last month. Another staff member interviewed stated that they have never ended the resident council or have prevented family from attending the meetings, and that the staff do address the recommendations and concerns of the family council when they are brought to staff's attention. During review of the admissions agreement for the residents, it details the right of resident families to join the resident council. In regards to the allegation that "Staff do not respond timely to resident's alerts," it is alleged that staff have not been responding to the residents' call pendant requests for assistance in a timely manner, sometimes taking up to 45 minutes to an hour. During interviews with the residents, seven (7) out of eight (8) did not corroborate the allegation. One of the residents stated that whenever they have used their pendant that they also respond to them in an appropriate time frame. Another resident interviewed stated that staff do respond in a very timely manner whenever they request assistance through their call pendant. During interviews with the staff, none of them corroborated the allegation. One staff member stated that they have been conducting ongoing training amongst staff on how to respond to the resident's pendants in an appropriate time frame. Another staff member explained that if a pendant is not responded to in a timely manner the managers are alerted to ensure that the resident gets the assistance they require as soon as possible During review of the Alarm Response Report for the date of 3/6/2025, over 90% of the call pendant requests were answered within 20 minutes. S2 explained there were some aberrations in the report where residents had left the facility or where the pendant was not reset after the resident received assistance. 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 to the allegation that "Staff allow a resident to be soiled while in care," it is alleged that staff have left a resident in a soiled diaper which led to the resident developing a rash. During interviews with the residents, none of them corroborated the allegation. One resident stated that they do receive all of the assistance and services they require. Another resident interviewed stated that they believe that all of their needs are being met by the facility staff. During interviews with the staff, four (4) out of five (5) interviewed did not corroborate the allegation. One staff interviewed stated that they never intentionally leave residents soiled in their incontinence supplies while in care, and that there are constant training amongst staff with regard to their incontinence care. Another staff interviewed stated that they have not heard of any issues with residents developing a rash due to not being changed, but they added that if this were to ever occur they would immediately notify the resident's doctor for guidance on next steps to treat the rash. 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 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 . Exit interview held, and a copy of this report was provided.

Program Analyst (LPA) Vaid made an unannounced visit to the facility to conduct a Case Management visit to evaluate the resident’s displacement by the Eaton Fire. LPA met with Health Service Director Laura Sanchez, and explained the purpose for the visit. There are currently seven (7) residents who were relocated from a facility in Altadena (MONTECEDRO 197610430) on 01/09/2025. LPA Vaid observed, and interviewed four (4) displaced residents. Three (3) residents were not available for interview. All residents interviewed feel safe and comfortable at the Bayshire facility but are anxious to return home to Montecedro. Residents interviewed stated, they are receiving good care, food is good, medications are administered timely as per physicians orders. Displaced residents interviewed reside in rooms: 155, 213, 214, 234. Residents room are clean and have bed, table, reading lamp, chair and linens. The water temperature was checked is between 105-120* F, within regulations. Residents are receiving the care and supervision they need. No health and safety concerns observed during the tour of the facility. Exit interview conducted and copy of this report was left with Health Services Director, Laura Sanchez.

Interviews conducted with staff revealed R1 full assistance with all activities of daily living (ADLs). R1 required staff to reposition at least every 2-3 hours. Per staff R1 was check for incontinence as well provided care as needed. If soil during the times R1 was reposition R1 was change. Staff stated to notify any changes in condition to hospice as soon as observed, including when noticing the wound patches were soiled. Hospice will come to the facility to change them after notifying them. Staff were provided training by facility and hospice and were knowledgeable on the topic. Interview conducted with hospice care nurse revealed facility staff have provided proper care to R1 and facility’s staff have notified hospice immediately after observing a change in condition. Documents reviewed revealed the following, per physician’s report dated 2/15/24, R1 had a history of skin breakdown and needed assistance with all ADLs. On 10/10/24, R1 was recertified into hospice care. Under circumstances for hospice, it was noted R1 has a recurrent “skin issue, with a healed decubitus to the sacrum/coccyx”. It was noted R1 was bedbound. On 10/30/24 hospice nursing notes, note R1 is being reposition every two hours by facility staff. On 10/31/24, a meeting was held and per hospice meeting notes, R1 is “high risk for skin breakdown and skin breakdown prevention was provided to facility’s staff, family and caregiver by demonstrating care”. On 11/4/24 nurse (LVN) hospice noted, R1 was observed to have “redness on coccyx, left buttock, right hip, and right upper back and shoulder”. R1’s facility resident assessment dated: 11/11/24 notes, R1 required “complex wound care”, which was to be provided by a nurse as order by physician. Hospice physician order dated 11/11/24 notes an x-ray was requested to rule out fracture for hand due to redness and swelling. Wound care was requested for right shoulder and lower back. Per Outside Agency - facility’s form, on 11/11/24 LVN visited R1 and provided wound care. On 11/11/24 facility provided skin integrity training to staff. Order summary report dated: 11/13/24, notes R1 will be receiving wound care for a stage II sacrum pressure ulcer three times a week. On 11/18/24 hospice physician conducted an in person visit and noted R1 has various lesions in the body and a stage I wound in the sacral area due to “frail skin”. Per physician these are "unavoidable" due to R1’s condition and may be "difficult to heal". Although the wounds may have developed based on physician’s notes on R1’s declining condition there is not enough evidence staff's lack of care would have cause the wounds. 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 Laura Sanchez Health Care Director and a copy of this report was provided.

The investigation revealed the following: In regard to allegation “Staff member works at the facility while under the influence” it was alleged that a staff member is arriving to work under the influence of alcohol. (6) of (6) denied the allegation. Staff member indicated that they do not come to the facility drunk and does not drink while at work. Staff indicated the following that they have not heard or witnessed an employee arriving to work intoxicated or drinking while working. Staff indicated they would follow reporting requirements if observed or suspected an employee working while intoxicated or drinking while working. (6) of (6) residents could not corroborate the allegation. Residents indicated they have not heard or witnessed a staff member working while intoxicated. In regard to allegation “Facility is dirty” it was alleged that kitchen and kitchen silverware is dirty. (6) of (6) denied the allegation. Staff indicated that they have not observed a dirty kitchen or residents eating with dirty silverware. Staff indicated a recent purchase of silverware was made on 10/17/24 for the reason of replacing current silverware with a matching set. Another reason for the purchasing of new silverware was to replace the current silverware that has water spots. (6) of (6) residents denied the allegation. Residents indicated they have not observed using dirty silverware. Resident indicated when at times observing water spots on the silverware but always clean. LPA Reyes observed with S3 the dish washer clean and operational. LPA Reyes observed S3 perform precision chlorine test paper and on the dish washer. Test paper indicated that dish washer is operating within operational requirements In regard to allegation “Facility is in disrepair” it is alleged that the facility’s doors are not being locked at night. (6) of (6) staff denied the allegation. Staff indicated that when they arrive in the early morning that doors are locked. Staff indicated the only way to gain entrance is through the main entrance of the skilled nursing facility or by contacting the telephone number listed at the facility’s main entrance. (6) of (6) residents could not corroborate the allegation. Residents have indicated no knowledge of the doors of the facility remaining unlock at night. In regard to allegation “Staff members do not have the required training” it is alleged staff CPR certificates are not current. (6) of (6) denied the allegation. S2 provided LPA Reyes with copies of the October 2024 staff schedule and a list of staff with current CPR certification. Per Title 22, Health and Safety code 1569.618 (3) for Residential Care facilities for the Elderly (RCFE) at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. (6) of (6) residents could not corroborate the allegation. However,neither resident had knowledge if the staffs on duty if CPR was current. **Continued-LIC9099-C** 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 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. Exit interview held. A copy of the report was provided.

Regarding the allegation: Staff do not ensure that resident(s) are provided with activities while in care. It was alleged that Resident #1 who is bedridden, can't watch TV, because TV is not working in the resident room. LPA tour the facility with HSD. Upon walking into the R1 room LPA observed that TV is on and R1 is watching TV. TV is working properly. Interviewed Administrator, HSD stated that they ensure that all residents have the opportunity to participate in activities. Residents care needs are individualized depending on their mobility and what they enjoy. Some residents like to watch TV, listen to music while others prefer visits from team members / staff. Interviewed S3 and S4 stated that if resident can't participate in a group activity, they have alternative activities for them. They do in room visits. They will bring sensory objects, read for residents or music therapy with the residents. 5 out of the 6 residents stated the staff would do activities with them. R1 stated that they liked to watch TV and TV was working in their room. Regarding the allegation: Licensee is not ensuring that staff provide adequate care to resident(s). It was alleged that facility did not have sufficient staff to provide care to resident, resident needs were not met. Staff didn’t change the resident diaper of extended period of time. R1 lays in their room without having diaper changed. Interviewed HSD, Administrator and staff denied the allegation. They stated that facility has enough staff to provide adequate care to residents in care. They assist residents with all their needs including diaper change all day and night. Facility has a 3-shift scheduled for morning, day, and night. They stated if there is a call off, they will replace the shift. It will be facility staff to work an extra shift or have an med. tech. or RCC (Resident care coordinator) fill in for that shift. Also, they have a contract with outside agencies if needed. Staff indicated that residents' diapers are changed every 2 hours, or as needed to keep them clean and dry. They also stated that each resident has pendant, and they can call/page staff if they need assistance and to have their diaper changed as well. LPA interviewed 6 residents of which 5 are incontinence. The residents interviewed stated the staff check their diapers often and change them as needed. R1 stated that staff do not leave them in soiled diapers. R1 shows their pendant and stated will call if need assistance. While LPA walked around to conduct resident interviews, LPA observed enough staff assisting residents. Continue 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 the allegation: Staff are not addressing resident(s) developing skin breakdown while in care. It was alleged that a lot of residents have bad skin breakdown. Interviewed HSD, Administrator and staff denied the allegation. They stated that protocol is to report any skin breakdown changes to the Med Tech and HSD (Health Service Director) who then discuss appropriate interventions with staff including Hospice care or Home health. Staff interviewed stated that they do rounds regularly to check on residents. Staff indicated that residents' diapers are changed every 2 hours, or as needed to keep them clean and dry. Staff also stated that they reposition resident to prevent rashes, skin breakdown. Staff also stated that when caregivers notice rashes or skin breakdown while assisting residents, they report it immediately to the Med Tech for assessment. Interviews conducted with residents were consistent with their response that the facility is providing adequate care to meet the needs of the residents. Based on the observations and interviews conducted with staff and residents, 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 to HSD Laura Sanchez.

Administrator and staff interviewed stated that the recent heat wave did cause some AC issues, but they immediately contacted a third party AC contractor to come and repair the AC issues. Administrator stated that portable AC were provided to residents affected to maintain a comfortable temperature. The third party AC contractor was interviewed and stated that it is normal for buildings like this facility to have AC problems here and there, but recently the heat wave caused a lot of AC units to stop working properly. The facility contacted him and he came to the facility on 09/06/24, 09/07/24, 09/08/24, 09/09/24 and 09/11/24. He stated he brought portable AC to install in rooms and areas that were affected while he worked on fixing the AC units. Every resident room has their own AC unit and thermostat. Six (6) out of eight (8) residents interviewed did not had any AC issues and had no complains about the temperature in their rooms. Two (2) of the eight (8) residents stated that their AC was blowing air, but not cold enough air especially during the recent heat wave, however, the facility provided them with a portable AC. LPA observed the thermostat in these 8 residents room and saw temperatures between 72 degrees F and 78 degrees F. Per Title 22 Section 87303(b)(2) and Section 87303(b)(3) , the facility shall cool rooms to a comfortable range, between 78 degrees F (26 degrees C) and 85 degrees F (30 degrees C), however, nothing in this section shall prohibit residents from adjusting individual thermostatic controls. LPA confirmed with the 8 residents if they were comfortable with the temperature showing on their thermostat and they stated they were. The residents are able to adjust the temperature in their bedrooms to their liking. Five (5) out of the eight (8) residents interviewed stated the temperature in the dining room was comfortable. Three (3) out of the (8) residents stated it was hot or warm in the dining room. These three residents stated that the temperature showing on the dining room thermostat showed temperatures of 81, 82, and 83 degrees F. These temperatures provided are within the temperature range per Title 22 Section 87303(b)(2). During today's visit, LPA observed a temperature of 78 degrees F in the dining room thermostat. 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. Exit interview held and a copy of the report was provided

All four (4) staff interviewed denied the allegation. Staff interviews revealed the facility AC is not leaking. LPA conducted a physical plant and observed the AC is working and not leaking. Thus, the facility’ AC is not in disrepair. In regard of allegation that the facility does not ensure equipment is properly maintained, it was alleged that the facility Hoyer lifts are outdated and not maintained. LPA interviewed residents, all four (4) out of four (4) residents could not corroborate the allegation. Residents’ interviews revealed that the facility Hoyer lifts were working properly and maintained by either hospice or home health agencies. All four (4) staff interviewed denied the allegation. Staff stated facility Hoyer lifts were operational and maintained. LPA observed staff operating the Hoyer lifts and they were working appropriately. Thus, the facility had maintained equipment and worked properly. In regard of allegation that the facility staff are not trained in the operation of the Hoyer lift, it was alleged that the facility staff are not trained to use the Hoyer lifts. LPA interviewed residents, all four (4) out of four (4) residents could not corroborate the allegation. Residents’ interviews revealed that the facility staff were able to use Hoyer lifts when providing cares. All four (4) staff interviewed denied the allegation. Staff stated facility had provided training to staff on how the operate Hoyer lifts properly. As mentioned above, LPA observed staff operating the Hoyer lifts and they were handling / working the Hoyer lifts appropriately. Thus, the facility staff were able to operate the Hoyer lifts. In regard of allegation that staff does not have appropriate qualifications, it was alleged that the facility’s acting Administrator is not qualified while the administrator was absent. LPA interviewed residents, all four (4) out of four (4) residents could not corroborate the allegation. Residents’ interviews revealed that the facility’s acting administrator was able to provide cares to residents as needed. All four (4) staff interviewed denied the allegation. Staff stated the acting administrator was able to perform the acting administrator’s job descriptions and provided guidance to staff. LPA reviewed staff records and current administrator certificates were observed. Thus, the facility staff have appropriate qualifications. (-continued in LIC9099C-) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 In regard of allegation that facility forced resident to change hospice companies against resident’s will, it was alleged that a resident was allegedly forced to change hospice companies against resident’s will. LPA interviewed residents, all four (4) out of four (4) residents could not corroborate the allegation. LPA interviewed the claimed resident who was forced to change hospice agencies. Resident’s interviews revealed that resident was aware of the changes and was not forced to change. Changes of hospice cares were due to the resident’s care needs and resident’s own wish. All four (4) staff interviewed denied the allegation. Staff stated staff would not force residents to choose their hospice agencies. Thus, the facility staff did not force residents to change hospice companies. In regard of allegation that staff did not meet resident’s care needs in a timely manner, it was alleged that that staff takes long time to respond to resident’s calls. LPA interviewed residents all four (4) out of four (4) residents could not corroborate the allegation. Resident’s interviews revealed that it usually took 10-15 minutes for staff to respond to resident’s calls and it was acceptable to residents. All four (4) staff interviewed denied the allegation. Staff stated they would response to resident’s calls as soon as they received them. Facility staff may assist with other residents while other residents called for assistance at the same time, staff would assist the new call as soon as they finished assisted other residents. LPA tested the call buttons during the physical plant, it took about 5-10 minutes to have a staff arrived at the rooms to assist residents. Thus, the facility staff did not fail to provide care to residents in a timely manner. 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 not preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegations are UNSUBSTANTIATED. An exit interview was conducted with Laura Sanchez, health service director and findings were discussed. A copy this report was provided at time of visit.

Interviews with staff revealed 3 out of 5 staff stated to not been aware of residents reporting any items missing, and staff usually assist when a resident leaves their personal belongings around. Administrator and health service coordinator stated that they had one resident report that money had gone missing, and they assisted the resident to look for the money, staff found money. However, the resident stated that was not the money that was missing. There have not been other reports of money missing from other residents in the last four months. Documents review revealed R1 is independent. Although the allegation may have happened there is not enough evidence that the money was stolen from the resident's room at this time. 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 Lisa Gomez and a copy of this report was provided.

S2 stated that a resident is reassessed when there's a change in condition and at that time, the appraisal/needs services plan and the physician's report are completed/updated. S2 indicated that dementia residents receive an annual medical assessment or as needed. Some staff interviewed stated that they address the needs of the residents based on the daily care assignments given to them and they ensure that residents are cared for with their activities of daily living. (6) out of (6) residents interviewed stated that they are comfortable living in the facility and staff attend to their needs. There was no mention of the specific resident(s) nor information provided as to which physician’s report was not updated timely. Documentation reviewed for (6) random residents in Memory Care and Assisted Living reveals that the facility maintains records of their Physicians’ report signed and dated by a physician, made within the last year. Some files also included up to date reassessment of the residents’ dementia care needs. Reviewed files also show the completed appraisal/needs and services plans identifying the functional capabilities and limitations of the residents. 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 and a copy of this report was provided to Chad Coleman, Administrator.

Residents interviewed stated they had not seen any lying around. In the memory care unit, anything that needs to be cut is usually prepared beforehand. Therefore, staff do not normally give residents scissors to cut and if they do, they will monitor the resident(s). Allegation - Staff left resident unattended. It is alleged that the staff left a resident with dementia alone in the assisted living side because the resident did not want to finish the walk. LPA toured the memory care unit which requires a code to exit. Per staff, residents are taken to the front of the facility for walks and to do community activities. They are always supervised by the wellness director and/or care staff. All the staff interviewed denied ever leaving a resident unsupervised in the assisted living area. They are aware that the residents residing in the memory care unit must be monitored at all times. Residents interviewed have not seen any residents being left unsupervised when they come out for walks or activities. For allegations - “Staff interfere with family council meetings” and “Staff did not follow up on family council meeting concerns in a timely manner”. It is alleged that the facility does not send out mailings or families are not made aware of the monthly meetings. The facility manager stated that they have a separate resident and family council meeting each month. The council meetings are posted by the sign-in sheet in the front lobby to inform them of upcoming meeting. She stated that the meetings are coordinated by the activity director. It was also noted that family members did not want residents to attend their council meetings as there is a separate resident council and would invite staff if they wanted them at the meeting. LPA interviewed residents who also stated they do not usually go to the family council meetings as those are mainly for families. As for following up on family concerns, the facility manager and staff who attended the meetings indicated they listened to their concerns and address them right away. 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 with Manager Lisa Gomez. A copy of this report along with the appeal rights was provided.

(5) of (5) Residents interviewed could not corroborate the allegation. Residents interviewed stated to have been receiving the proper services to care for their needs. File review shows that the facility has been updating and creating needs and services plans for residents every 6 months or when needed. Interviews with staff all explained that needs and services plans are also updated when there are any change in conditions to residents and it will be detailed on the same form. Based on interviews conducted, files reviewed, and observations there was not enough supportive evidence to concur with the reported allegation; 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. In regards to the allegation "Facility did not update physicians reports for residents with a change in condition" it alleged that resident physicians reports are outdated and not updated as needed. (5) of (5) Staff interviewed denied the allegation. (5) of (5) Residents interviewed could not corroborate the allegation. LPA was not provided with specific information as to which residents had changes in condition not updated. Per Title 22 Regulation, Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. Regulations add that the licensee shall obtain an updated medical assessment when required by the Department. Review of the residents files shows that the facility acquired physician reports (medical assessments) for the residents prior to admitting them to the facility. There are no documents on file of the department requiring the facility to update physicians reports. Per Title 22 the facility must also ensure that a resident with dementia shall have an annual medical assessment done at least annually, which shall include a reassessment of the resident’s dementia care needs. File review shows medical assessments done for residents with dementia within that timeline. Based on interviews conducted, files reviewed, and observations there was not enough supportive evidence to concur with the reported allegation; 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. Exit interview conducted and a copy of this report was provided.

All interviewed staff stated that the Assisted Living's main telephone line is switched to night mode at 8pm. On night mode, all calls are automatically transferred to the SNF's nursing unit station where staff are available to answer calls. S4 also stated that she is the back up receptionist and comes in early. (1) out of (6) residents interviewed stated that she had seen the staff come in late and that the front door does not get opened until after 8am. (6) out of (6) residents interviewed stated that they are receiving calls through their cell phones and not transferred from the main line. All interviewed residents stated that they never had an issue with receiving or making calls. During today’s visit, LPA observed the residents carrying their cell phones and staff answering the incoming calls from the main line. LPA also observed (3) after hours phone numbers posted outside the main door. Therefore there was insufficient evidence to corroborate with this allegation. Based on observations, 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 held, and a copy of this report was provided to Lisa Gomez, House Manager.

In regards to the allegation "Air conditioner is in disrepair" it was alleged that the AC in room #166 was not working and the HVAC system for the facility has not been working for a month. (6) of (6) Staff interviewed denied the allegation. (4) of (4) Residents interviewed could not corroborate the allegation. Room #166 is in the facilities memory care unit and LPA observed the AC to be working. LPA observed the AC for the rooms in the memory care unit that were toured to be operating. Staff interviewed denied knowledge that any rooms have a broken AC and added that temperatures are set on the thermometer for each room. Staff interviewed stated they will address any issues as soon as they are aware of them. File review shows that for the month of June there was (1) room with AC issues and it was addressed for room #240. There are no documents on file showing that the HVAC system has been out for a month or that the AC in room #166 was in disrepair. Based on interviews conducted, files reviewed, and observations there was not enough supportive evidence to concur with the reported allegation; 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. Exit Interview conducted and a copy of this report was provided.

S3 stated that the facility has a dietitian that reviews and approves their weekly menu or when there’s any changes to the menu. Staff indicated that med tech or charge nurse provides the kitchen staff a list of residents with special/restricted diet. Staff indicated that food requirements for residents are communicated to the kitchen staff verbally and also through a kitchen bulletin board. Interviewed staff stated that there is a board in the kitchen to pass notes among the kitchen staff and board also reflects Residents dietary needs (diabetic, no/low salt, food allergies, preference, requests, etc.). Interviews conducted with residents revealed that staff meet their dietary needs. (5) out of (12) interviewed residents are on a special diet. (12) out of (12) interviewed residents indicated they do not have any concerns regarding their diets. During the review of the facility records, LPA observed that the facility keeps a list of the dietary needs and restrictions of the residents as ordered by their physicians. LPA toured the kitchen and the dining area and observed the food served to residents were on the menu. LPA also observed that the residents dietary needs list is posted on the board. Therefore, there was insufficient evidence to corroborate with this allegation. In regards to the allegation: “Staff do not provide adequate amount of food to residents.”, it is alleged that too small quantities of food are provided to the residents without second servings being offered. No other details provided. Staff interviews revealed that staff provide adequate food service to residents. Staff indicated they follow a menu reviewed and approved by a dietitian. Staff also stated that they provide alternative food menu for residents. Interviewed staff stated that they always provide huge amount of servings to the residents. Per staff interviewed, they have not heard or received complaints regarding the amount of food being served to the residents. Interviewed residents indicated the staff provide adequate food service including snacks and do not have any concerns. Interviewed residents indicated that the food servings and portions are adequate. During today’s visit LPA along with S3 toured the Kitchen and pantry areas and LPA observed sufficient food supplies. Between 12pm-12:30pm, LPA toured the dining area during lunch and observed the quantity of food served to the residents are adequate. Therefore, there was insufficient evidence to corroborate with this allegation. Based on statements and interviews conducted with staff, residents, review of facility file records, there was not enough supportive evidence to concur with the reported 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. Exit interview held, and a copy of this report was provided to Lisa Gomez, General Manager.

The manager stated that this is not true and that they have the CCLD complaint hotline poster in the main lobby and anyone is free to call CCLD to file complaints. LPA confirmed that the CCLD complaint hotline poster is posted in the main lobby where is visible. Staff and residents interviewed denied the allegation. Regarding the allegation " staff did not treat resident with dignity and respect ", it is alleged that the manager is mean to the residents. The manager denied this allegation and stated she is respectful towards all residents. Staff and residents interview did not corroborate the allegation. 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. Exit interview held and a copy of the report was provided

R1-R6 all stated they have not observed S2 not giving anyone their medication and that it is always given per physician's directions. 1 resident who takes an inhaler stated that Staff S2 has never given more than 2 puffs as prescribed by the doctor and gives it the way she is suppose to. R1-R6 all stated that Staff S2 does not bully anyone and does her job. Spoke with staff who stated that there have been no complaints against Staff S2. Also stated that they will look at the MAR's Log on the computer and if eligible will get the pain med. Order will be for either every 6 hours or 8 hours and only if not eligible would a resident get Tylenol. All staff stated they follow doctor's orders and don't give any medication that is not prescribed. 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 with Manager Lisa Gomez.

Staff interviewed stated that they do ensure that the carpet is clean and sanitized. Residents interviewed did not corroborate the allegation. Six out of six residents stated that the staff frequently clean the carpet. 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. Exit interview conducted, and a copy of the report was provided to Ms. Gomez.

Regarding the allegation: Facility is in disrepair. it was alleged that " Place is in disrepair”. Staff interviewed denied the allegation. Staff stated that if anything is in disrepair, they put online maintenance/ work order, and the maintenance person will repair it in a timely manner. LPA toured the facility including randomly chosen residents rooms and observed that facility is in a good condition. All interviewed residents stated that everything works in their rooms and not aware of facility being in disrepair. Regarding the allegation: Facility staff do not provide meals of the quality necessary. It was alleged that "Kitchen doesn’t offer adequate food". Interviewed staff and residents denied the allegation. LPA obtained a copy of the facility menu, and reviewed facility food supply. LPA observed a variety of food available and a sufficient quality. LPA toured the facility kitchen and observed an ample supply of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. LPA observed bread, grains, meats, fruits, vegetables, eggs, juice, milk, and snacks in the kitchen / refrigerator / freezer. Staff and residents interviewed stated that residents can request an alternate meal if they don't want what is being served. Interviewed staff indicated they have not received any complaints about food/meal. Interviewed residents had no concerns about quality of food/meal. Regarding the allegation: Laundry room does not have adequate supplies. It was alleged that "Laundry room isn’t equipped with supplies". Interviewed Staff denied the allegation. Health Services Director (HSD) and Staff # 4 denied the allegation stating that facility never runs out of the laundry supplies. LPA toured the laundry rooms and observed that each laundry room has a laundry detergent / soap dispenser, and they are full. Several large gallons of laundry detergent / soap observed in the main laundry room located at the first floor. LPA also observed boxes of plastic bags that staff use to separate the resident’s dirty and clean clothes, and different kind of laundry / cleaning supplies. Interviewed residents stated that they are not aware of laundry supplies at the facility. Continue 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 the allegation: Facility does not have a qualified administrator. It was alleged that "Administrator doesn’t qualify for managing". Chad Coleman is the administrator of the facility and on this position since 04/01/24. LPA reviewed the administrator file and observed that Chad Coleman has a Bachelor’s Degree, which meets the educational requirements for the administrator. He has an experience providing residential care to the elderly since 2019. He has an active Administrator Certificate, which expired on 05/10/2025. HSD O'Neel mentioned that she also has Administrator certificate for RCFE, and she is designated person in case of administrator absence (Copy of LIC308 was provided). She has (2) years completed of college, which meets the educational requirement of (2) years and has experience in providing residential care to the elderly since 2018. She currently has an active Administrator Certificate, which expired on 12/08/2024. Based on interviews, records review and observations the investigation revealed: 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 with HSD Heather O'Neel, and a copy of this report was provided.

Allegation: Staff do ensure the facility's communication devices are properly operating. It was alleged that during the last weekend of March and thru the April first there was no internet at the facility and communication systems have stopped, including individual resident pendants each resident carries to call / page for assistance. It was reported that residents could not call for and get assistance. Interviewed HSD stated that on April 1st, 2024, Bayshire took over ownership of the building / facility. During that transition they replaced all the internet / Wi-Fi access points and internet switches in the building. Work started April 1st in the morning, approximately from 7am.- 12 pm. During that time the pendant system was down. All interviewed staff stated that for residents safety, 30 minutes to 1 hour checks were done on every resident. All staff including Care staff, Med. Techs, RCC (Residents Care Coordinator) and nurses were involved in these checks. Interviewed IT confirmed that work done at the facility on April 1st, and it took about 4-5 hours. All interviewed residents stated that their pendants are working, and they can call for the assistance if they needed. During the visit LPA ask randomly chosen residents to push the pendant button and observed that residents pendants are operational, and the staff came in to check with residents in 2-3 minutes. Based on the observations and interviewed conducted with staff and residents, 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 to Heather O'Neel.

Licensing Program Analyst (LPA) V. Maldonado made an announced visit at the facility for the purpose of conducting a Pre-Licensing Inspection, using the Compliance and Regulatory Enforcement (CARE) Tool, to evaluate the facility. LPA Maldonado met with Applicant, Scott Kirby, and explained the purpose for the visit. This is a Change of Ownership. Applicant has requested to operate as a Residential Care Facility for the Elderly. Per the application received, applicant has requested a fire clearance to serve (114) older adults, ages 60 and over, of which (104) will be non-ambulatory, and (10) will be bedridden. Applicant has also requested to care for residents with dementia, and has a pending Dementia Care Plan. The dementia unit currently has delayed egress. The department has not received an approved fire clearance yet. Per the applicant, a Hospice Waiver was requested to care for (20) residents. However, LPA did not receive any documentation from the Centralized Application Bureau indicating it has been approved. There are currently (12) residents receiving hospice services. The facility is a three-story building. The assisted living section has 90 resident bedrooms and has a separate dementia unit with 23 resident bedrooms. An Infection Control plan has been submitted and approved by the department. The facility has an active and current liability insurance policy on file. During today's visit, LPA Maldonado conducted a tour of the physical plant with Applicant, observed the facility food supplies, reviewed (5) resident medications, (5) resident files, and (5) staff files. LPA inspected random bedrooms on all (3) floors. Resident bedrooms were observed to have the required furniture, sufficient lighting, and closet/storage space. Resident bathrooms and shared shower rooms were equipped with required grab bars and non-skid mats. The hot water was tested and measured between 113*F-117*F, which is in compliance. Food supplies was observed and was sufficient as required. Fire extinguishers were observed throughout, with current inspections and were fully charged. All sharps and cleaning supplies/toxins were observed to be locked and inaccessible to residents in care. There is an electric fireplace in the lobby/dining room covered with a screen. The last fire drill was conducted on 2/16/24. Auditory devices were observed at all entrances/exits of the memory care unit and were operational. (Report Continued on LIC9099-C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 The signal system in resident bedrooms were tested and operational. There is sufficient indoor and outdoor activity space for residents. There are (2) courtyards in assisted living and an enclosed patio in memory care with shaded seating areas. Evacuation chairs were observed at each stairwell. Water fountains were observed in the courtyards of assisted living and are inaccessible. All required postings were observed throughout the facility. Sufficient additional linens/towels were observed. The laundry areas are kept locked and inaccessible to residents at all times. Resident files and staff files were reviewed and observed to be complete with all required documentation. Resident medications were reviewed and observed to be documented properly and given as prescribed. During the pre-licensing inspection, items were observed which do not comply with applicable laws and regulations. The following items must be corrected: An approved Fire Clearance has not been received by the department Applicants have been notified to contact LPA Maldonado once the corrections have been made. The physical plant was not cleared during today's inspection, due to the corrections needed. Component III orientation has been waived by applicant today, due to being completed for another licensed facility within the last year. An exit interview was conducted with applicant and a copy of this report has been furnished. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.

Facility Type: RCFE Application Type: CHOW Capacity: 114 Interview Method: Telephone interview On 3/19/2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readiness