Coterie Cathedral Hill.

On 12/8/2025, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct the Annual 1-year required inspection. LPA Calandra was greeted by Matthew Turner, General Manager and explained the purpose of the visit. LPA reviewed 10 resident files. All were observed to be complete except for one resident, R1 that was missing Ambulatory or Non-Ambulatory status listed in their Medical Assessment. During file review, LPA observed that one resident, R1 was missing Ambulatory or Non-Ambulatory status listed in their Medical Assessment. A Technical Violation was provided for this. LPA reviewed 8 staff files. All were observed to be complete. A review of Centrally Stored Medications indicated that medications for residents were properly labeled with instructions on dosage and times of day and matched the Centrally Stored Medication Records(CSMR) kept at the facility. LPA collected 3 Administrator's certificates. No deficiencies cited during today's visit. The Annual inspection will be completed at a later date. An exit interview was conducted. This report was reviewed with facility representative and a copy provided via email.

Complaint also alleged that staff did not respond to resident’s call button in a timely manner. Reporting Party alleged that when R1 pushed their call button, no staff would respond. Based on interviews and record review, the facility’s policy is for caregivers to respond to call buttons within 10 minutes or less. Based on interviews, it takes staff less than 10 minutes to respond to a call button and if they are busy, other caregivers can be called on to help. Complaint also alleged that staff did not provide services to resident as specified in their care plan. Per interview with Reporting Party, R1 was to get showers on a daily basis per their care plan and status checks throughout the day. According to the Reporting Party, status checks were not done in person. Based on interviews and record review, R1 did ask for a shower every day and was provided one by their 1:1 caregivers as R1’s private caregivers asked the facility staff not to provide care. Complaint alleged that staff did not notify resident's responsible party of changes to R1's care plan. Based on document review and interview, the facility’s Care Coordination Director and Regional Care Director contacted R1’s responsible party and discussed each update to the care plan with the responsible party. Complaint alleged that staff overcharged resident. According to the Reporting Party, R1’s level of care costs were raised from $2,200 to nearly $6,000. Based on document review and interview, R1’s needs changed over time and thus R1 was reassessed by the facility’s Care Coordination Director and Regional Care Director. They notified R1's responsible party of the change who agreed to the change in level of care and cost associated. In addition, based on document review and interview, level of care and monthly charges are explained in the facility's admission agreement. 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 above allegations are unsubstantiated at this time. No deficiencies cited during today's visit. An exit interview was conducted. This report was reviewed with facility representatives and a copy provided.

On 11/10/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management visit in response to an incident report received on 10/08/2025. LPA met with assistant general manager Armando Prado and explained the purpose of today's visit. According to the incident report received, the resident fell while outside of the facility and hit their head. Resident was brought back to the facility by a good samaritan. The facility called 911 due to the injury to the head and the resident was evaluated at the hospital and the facility notified responsible parties and the primary care physician of the resident. The resident returned to the facility with discharge instructions. LPA reviewed the file of the resident and found that the resident is allowed to leave the facility unassisted. The resident walks on their own and is ambulatory with no walking aids or devices. The resident goes on walks on their own regularly outside of the community. The resident is back in the facility and has recovered back to baseline with no injuries or changes in status. No citations issued. Report is reviewed with Armando and a copy is provided.

On 11/6/2025, Licensing Program Analyst (LPA) Murial Han conducted an unannounced case management visit to follow-up on an incident that was reported by the facility. LPA met with administrator, Matthew Turner and explained the purpose of today's visit. On 10/13/2025, CCL received an incident report from the facility concerning to an incident that happened on 10/10/2025 in which resident #1 (R1) slapped resident #2 (R2)'s as R1 reported that R2 pinched his/her hand. This incident was witnessed by the Memory Care Director who discouraged R1 from hitting another resident. The facility reported the incident to R1 and R2's responsible party. The facility conducted an assessment of R2 and there was no injuries noted. During today's visit, LPA met R1 and R2 and attempted to speak to R1 but he/she did not want to speak to LPA. The administrator stated that both residents are doing well and there were no further aggressive behaviors from both. No deficient is cite. This report is reviewed and discussed with the assistant general manager. A copy is provided.

On 09/30/2025, Licensing Program Analyst (LPA) Yi Sam Jian conducted a case management visit concerning a report of suspected abuse re ceived on 9/22/25. LPA met with administrator Matthew Turner. LPA explained the purpose of today's visit. Regarding the report, an unknown caller contacted resident R1, pretending to be from the facility and requested a money transfer. R1 provided bank information to the caller, and the money was subsequently transferred. L PA conducted an interview with the Administrator and obtained the following information: the facility submitted an incident report to Community Care Licensing (CCL) for review. According to the admission agreement, R1 and her husband—both residing in assisted living—are listed as the responsible parties. The resident’s son accompanied R1 to the facility office to report that she had shared her bank information with an unknown caller. The resident’s daughter also contacted the facility to confirm whether the facility had called R1. The facility confirmed that no such call had been made. The daughter then informed the facility that funds had indeed been transferred to the unknown caller. Facility does not contact residents by phone to collect payments, as all payments are handled through an online portal. Residents received scam calls from outside sources. Staff receive annual training on theft and loss prevention. In response to this incident, a scam prevention notice was also sent to all residents. A copy of the police report was not available, and no report number was provided, as R1 filed the report independently. No additional relevant information or documentation was available at the time of the visit. The LPA requested copies of the resident’s admission agreement (including the Theft and Loss Program notification), the resident’s medical report, care plan, and reassessment. No deficiencies cited today. Report was discussed and a copy of the report is provided.

On 2/27/2025, Licensing Program Analysts (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by General Manager, Matt Turner. The facility currently provides care for 193 residents, 6 of which are receiving hospice services along with a designated memory care unit. LPA continued with a tour of the facility with staff, facility found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common spaces and kitchen and food storage areas were inspected. Fire Extinguishers located throughout the building were found to be charged. Smoke and carbon monoxide detectors and fire safety systems are interconnected with last fire safety inspection completed October 2024 with all corrections completed. Cleaning supplies and other toxins are safely stored in locked closets throughout the facility, and housekeeping/maintenance rooms all of which were secured upon inspection. There was a supply of hygiene products and paper products available for residents. All resident’s bedrooms were found to be in a clean and comfortable condition with lighting & appropriate furnishings and bedding items. Residents were observed to be out in the community during the inspection, interacting with staff, fellow residents and visitors in the common areas, or in their bedrooms resting. The facility encourages regular family visits and utilizes a wide variety of activities with LPA observing staff engaging continuously with residents, offering a unique variety of activities and outings based on individualized preferences and capabilities. A wide selection of activity supplies and amenities including a gym, pool, large outdoor patio and guest performances are all provided. LPA found that staff and resident engagement is well practiced with activity calendars developed on a monthly basis with residents observed to have a positive and personable relationship with staff and General Manager. Continued onto LIC809-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 LPA conducted a sample file review for several residents and found all items to be on file including Needs & Service Plans and Medical Assessments to be current. Upon a spot check of staff files, LPA found that caregiver staff have current first aid and annual training, health screenings and TB results on file. Lastly, a spot check of medications was conducted and found that all medication counts and records are in order. Administrator, Deborah Suarez's Administrator Certificate 7008093740 is valid through 5/15/2025 General Manager, Matthew Turner's Administrator Certificate 6074366740 is valid through 1/28/2027 LPA requested the following documents be sent to CCL by COB 3/13/2025: LIC 308 Designated Facility Responsibility LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan Liability Insurance No deficiencies cited during today's visit

LPA gathered further information regarding (R1) ADL medication care needs are not met. Complainant reports that staff had administered R1's medication over one hour past scheduled medication administration times. Upon interviews with Care Coordinator Director (S2) and documented statements of General Manager (S1) gathered, it is indicated that the facility staff are allowed to administer medication one hour before or one hour after medication administration times. Upon review of facility medication administration policy LPA confirmed that it is also indicated: staff are "allowed" to assist up to one hour before or after the medication "give time". There however, is no indication in facility policy that staff are required to provide medications at exact times. S1 further indicated that staff are to provide services or attempt to provide services to residents at approximates of schedule times with consideration to staff tending to several other residents in care. In addition, LPA reviewed medication prescription instruction for R1's prescribed Amoxicillin with claims that medication was not administered within prescription time frame. Upon review of medication prescription, Amoxicillin is only indicated to be taken 3 times per day (AM, PM and Evening) with no specific times that the medication is required to be taken at. Lastly, LPA conducted a file review of facility Medication Administration Records (MAR) in which all indicated dates in which staff allegedly failed to meet resident R1 medication assistant ADL were found to be marked as completed. Due to a contradicting information gathered an a lack of corroborating evidence, the allegation is found to be unsubstantiated. A finding that the complaint allegations, facility staff not meeting resident needs is unsubstantiated meaning that although the allegation 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.

On February 16, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct the unannounced Annual 1-year required Annual Inspection. LPA Calandra was greeted by Collin Hardwick, Concierge. Deborah Suarez, Assistant General Manager and Shirley Cheung, Care Coordination Director, and Matthew Turner, General Manager arrived later. LPA Calandra toured the physical plant. This is a fourteen story building that consists of 144 bedrooms. Water in all bathrooms was measured between the required 105-120 degrees Fahrenheit. Bathrooms were observed to have the required grab bars and anti-skid mats. Fire extinguishers in the facility were observed to be fully charged and last inspected on January 30, 2024. The facility had the required 7 days of non-perishables and 2 days of perishables on site. No food was expired. The kitchen refrigerators and freezers temperature were within the required range. All bedrooms were sufficiently lit and had the required furniture. The outdoor space was clear from obstructions. No accessible bodies of water or hazards were observed. The facility does not handle any cash resources. The facility was maintained at a comfortable temperature of 70 degrees Fahrenheit. LPA Calandra reviewed 5 resident files and 5 staff files. All were observed to be complete. LPA Calandra also interviewed 3 staff and 3 residents. All knives, sharp objects, soaps, detergents, and medications were observed to be locked and in-accessible to persons in care. A review of Centrally stored medications indicated that medications for residents were properly labeled with instructions on dosage and times of day and matched the Centrally Stored Medication records(CSMR) kept at the facility. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LPA Calandra received the following documents at the facility: -Trainings completed by Assistant General Manager, Deborah Suarez -Administrator's Certificate for Deborah Suarez -Updated LIC 500 reflecting all staff No deficiencies were cited during today's visit. A copy of the report was reviewed with Deborah Suarez, Assistant General Manager, Shirley Cheung, Care Coordination Director, and Matthew Turner, General Manager and a copy left at the facility.

On October 25, 2023, Licensing Program Analyst(LPA), John Calandra and Licensing Program Manager(LPM), Cara Smith arrived at the facility to follow up in regards to an incident report received on September 21, 2023 regarding a resident who left the facility unattended. LPA Calandra and LPM Smith were greeted by Shirley Cheung, Care Coordination Director, Sarah Laloyan, Senior Vice President of Operations, and Deborah Suarez, Assistant General Manager and explained the purpose of their visit. Shirley Cheung and Sarah Laloyan, informed the LPA and LPM that the resident had left the facility with other residents for a community walk with their spouse. The resident came back to the community and notified the front desk staff that they would like to continue their walk. The resident did not sign in or out via the Accushield system.This is not considered an abnormal practice based on an interview with Deborah Suarez, Assistant General Manager. LPA Calandra and LPM Smith reviewed and collected several documents including the resident's LIC 602, list of activities for the day, notes regarding the incident, Absentee notification plan, etc. At this time, there are no deficiencies cited. A copy of this report was reviewed with Shirley Cheung, Care Coordination Director, Sarah Laloyan, Senior Vice President of Operations, and Deborah Suarez, Assistant General Manager and left at the facility.

Amended Report On 8/28/2023, Licensing Program Analyst (LPA) Grace Donato conducted a case management visit concerning a report of suspected abuse received on 8/7/23. LPA met with Shirley Cheung, Care Coordinator Director & Deborah Suarez, Assistant General Manager. LPA explained the purpose of today's visit. In regard to the report, resident (R1) mentioned that a private duty aide (PDA) sexually abused him/her. Based on record reviews & interviews, in the admission agreement, pages 6-7 pertaining to Private Duty Aides, Outside Services, R1 is allowed to hire, but hired PDA is to follow rules in the community. The PDA is fingerprinted through the agency. PDA was removed from the facility when the report was made. Currently, facility has suggested to residents to hire from the facility's preferred agencies. Document to be submitted LPA regarding records for the Private Duty Aide. No deficiencies cited today. Report was discussed and a copy of the report is provided.

Page 2 - LIC9099 Positive residents are isolated in their rooms and visitation guidelines are in place requiring visitors to wear N95 masks and face shields if visiting. Staff members in memory care are observed wearing N95 masks and face shields during tour. Notifications to family members are going out on this day due to DPH outbreak status being declared. No staff have tested positive at this time. Facility is abiding by current Provider Information Notification updates at this time. This allegation is unfounded. This agency has investigated the complaint alleging, Staff did not comply with infection control practices resulting in a H&S risk . We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. No citations issued. Report is reviewed with Deborah Suarez.

Regarding the allegation that staff do not meet residents hygiene needs while in care, according to the reporting party, the residents on the 4 th floor with scabies are not being bathed nor changed. During the investigation, LPA interviewed the Executive Director, Assistant General Manager, Deborah Suarez, and Care Coordination Director, Shirley Cheung and reviewed resident files. According to the Executive Director and staff interviewed, they denied this allegation. Based on the staff interviewed, it was indicated that when the facility received confirmation on 7/21/2023 that R1 tested positive for scabies, all residents and all staff in the memory care unit were treated with the scabies prescription on 7/22/2023. Furthermore, on 7/23/2023, all resident apartments were cleaned, staff provided all memory care unit residents with showers, changed their linens and laundered their personal clothing. Therefore, based on the interviews conducted, and information collected, the allegations above are UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred. Report is reviewed with the Executive Director, Sarah Lolayan and a copy is provided.