Ivy Park at Cathedral Hill.

On 05/13/2026, San Bruno Regional Office conducted a non-compliance conference meeting with Chief Operations Officer, Matt Stevenson, Scott Carlson, Senior Vice President of Operations, Jenn Sato, Senior Vice President of Operations, Patricia Murphy, Regional Director of Operations, Safoora Ahmed, Vice President of Memory Care and Programming, Kevin Wrigley, Vice President of Regulatory, and Chris Schuster, Executive Director, and Joel Goldman, Partner at Hanson Bridgett LLP. Present in the meeting were Regional Manage Jackie Jin, Licensing Program Manager Brenda Chan, and Licensing Program Analyst John Calandra . During the non-compliance meeting, the following serious violations were discussed: 87465(h) Incidental Medical and Dental, 87466 Observation of Resident, 87405(a) Administrator Qualifications and Duties, 87463(a) Reappraisals, 87468.2(a)(4) Additional Personal Rights of Residents in All Facilities, 87468.1(a)(2) and 87468.1(a)(6) Personal Rights of Residents in All Facilities, 1569.312(a) Basic Services, and 87411(a) Personnel Requirements. During this meeting, the compliance plan was developed and discussed with the licensee which includes more frequent monitoring inspection visits to ensure compliance with this compliance plan and Title 22 Regulations for 2 years. Licensee was provided the link below for resources and guidance to improve facility operations: https://www.cdss.ca.gov/inforesources/community-care/resource-guide-for-providers . This report was reviewed with Chief Operations Officer, Matt Stevenson, Scott Carlson, Senior Vice President of Operations, Jenn Sato, Senior Vice President of Operations, Patricia Murphy, Regional Director of Operations, Safoora Ahmed, Vice President of Memory Care and Programming, Kevin Wrigley, Vice President of Regulatory, and Chris Schuster, Executive Director, and Joel Goldman, Partner at Hanson Bridgett LLP. A copy of the report was provided.

On 2/26/2026, Licensing Program Analyst(LPA) John Calandra arrived at the facility to complete the 1-year required inspection. LPA Calandra was greeted by Kelly Phillips, Health Services Director and explained the purpose of the visit. LPA toured the physical plant. This is a five story building with 180 bedrooms, 180 bathrooms, common spaces, a backyard, and memory care unit. No accessible bodies of water or hazards were observed. LPA toured random rooms. All rooms had the required furniture and sufficient lighting. All bathrooms had anti-skid flooring and floor mats and grab bars. The facility's fire alarm and Carbon Monoxide detectors were observed to be functioning properly and according to the facility's maintenance director were directly connected to the San Francisco Fire Department. The facility's fire extinguishers were observed to be fully charged and last checked on 10/27/2025. The facility had the required 7 days of non perishables and 2 days of perishables on site. No food was expired. The facility's first aid kit was observed to have the required items. All sharp objects, soap, detergent, and poisons were observed to be locked and in-accessible to persons in care. LPA reviewed 6 staff and 5 resident files during yesterday's visit. No deficiencies cited during today's visit. An exit interview was conducted and a copy of the report provided to the facility representative.

Complaint alleged that clothing, shoes, and bedding have gone missing from R1's room and have not been returned or misplaced by the Licensee. Based on interviews of the Administrator and staff, the facility made reasonable efforts to safeguard R1's property by providing a secured room and by labeling R1's articles of clothing and other items. In addition, the Licensee found/returned or in some cases, replaced any missing items or provided reimbursement per their theft and loss policy. Complaint alleged that resident had missed several medical appointments. Based on interviews of staff, R1's responsible party takes them to medical appointments. In addition, many of R1's appointments take place inside of the facility. On some occasions, R1 has refused to go to their medical appointments and facility staff have talked to R1 about it but R1 has still refused. Although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted. A copy of the report was provided to the facility representatives.

On 1/29/2026, Licensing Program Analyst(LPA) John Calandra, arrived at the facility to follow up on a self-reported incident involving a resident, R1 who was reported to have taken their own life. LPA Calandra was greeted by Kelly Philips, Health Services Director and explained the purpose of the visit. According to the Administrator, Chris Schuster and Kelly Philips, Health Services Director, R1 was found unresponsive in their own room by staff. R1 was reported to be completely independent (did not receive medication assistance or any other types of services) and kept to themselves. On the day of the incident, a member of their Health Services team called 911 who came to the facility and are currently investigating the situation. During the visit, LPA interviewed staff and obtained the following records: staff self-attestations of the event LIC 602: Physician's report Appraisal of Needs and Services LPA requested copies of the following documents by 2/6/2026: Incident Reports submitted regarding R1 R1's care notes No deficiencies were cited during today's visit. An exit interview was conducted. A copy of this report was provided to the facility representative.

On 12/23/2025, Licensing Program Analyst(LPA) John Calandra arrived at the facility to deliver an Amended report originally delivered on 10/19/2025. LPA Calandra was greeted by Chris Schuster, Executive Director/Administrator and explained the purpose of the visit. Licensee surrendered the original copy of the report. No deficiencies cited during today’s visit. An exit interview was conducted. A copy of this report was provided to the facility representative.

On 12/23/2025, Licensing Program Analyst(LPA) John Calandra arrived at the facility for the purpose of following up on a complaint received by the Department on 7/11/2025. LPA Calandra was greeted by Chris Schuster, Administrator and explained the purpose of the visit. During the course of the investigation, the Department learned that the facility had admitted R1 who was considered a fall risk but did not create a fall prevention plan to meet R1’s needs. A Type B citation was provided for this deficiency. The Licensee was cited for this deficiency on 10/13/2025. This case management is in regards to the complaint #14-AS-20250711142309. A Plan of Correction has already been provided for this citation. Deficiency cleared during visit. Deficiencies are cited under the California Code of Regulations, Title 22. Failure to correct the deficiencies by the due date may result in civil penalties. An exit interview was conducted. A copy of this report along with Appeal Rights was provided.

On 10/13/2025, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct a Case Management visit in regards to a Change in Management request. LPA Calandra was greeted by Kelly Phillips, Health Services Director and explained the purpose of the visit. LPA Calandra requested the following documents by 10/17/2025: - Updated LIC 200 with new administrator name. -LIC 501-Personnel Report -LIC 503-Health Screening Report -Copy of photo ID -Copy of current Administrator Certificate -Copy of First Aid/CPR Certificate -Fingerprint clearance. -Updated LIC 610E Emergency Disaster Plan -Updated LIC 9282 Infection Control Plan -If you signed the hospice waiver request, please submit new request for new administrator. -Board Resolution Letter(Letter appointing the new administrator from the Board) No deficiencies were cited during today's visit. An exit interview was conducted. This report was reviewed with facility representative and a copy provided.

Complaint also alleged that facility staff are not reporting incidents involving residents as necessary. Based on interview and document review, there were several occasions in which R1 fell but the Licensee did not complete a written report within 7 days of the occurrence of the event for 9 out of the 10 falls. Based on information reported by and obtained from facility staff and witnesses, these allegation is substantiated. The preponderance of evidence standard has been met. Deficiencies are cited under the California Code of Regulations, Title 22. Failure to correct the deficiencies by the due date may result in civil penalties. An immediate civil penalty of $500.00 was issued and a copy of the LIC 421IM was given to Chris Schuster, Administrator/Executive Director. At the time of the complaint inspection on 12/23/2025, licensee was informed that the incident is currently under review and a future civil penalty may apply based on Health and Safety Code § 1569.49. Exit interview conducted. A copy of the report issued. Appeal Rights provided. Facility representative signature on this report acknowledges receipt of the Appeal Rights, found on page two of LIC 421IM.

On 3/26/2025, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of continuing the Annual Required - 1 Year Inspection and was greeted by Executive Director, Fili Igafo. LPA completed a tour of the remaining portions of the facility including additional resident apartments, kitchen and food storage area and facility vehicles. LPA continued on tour of the facility with staff and found all exits and doorways to be free from obstruction. Exit stairwells were all equipped with evacuation chairs and elevators were found to have current inspection permits. Resident bedrooms were found to be in a clean and comfortable condition with housekeeping and laundry services provided on a weekly basis. All resident rooms are equipped with signaling system that directs to staff pagers. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations, with food stored in the kitchen, sufficient for residents in care. Food supply is replenished multiple times per week or as needed and stored properly. Facility provides a wide variety of meal preferences and preparation while also ensuring proper dietary restrictions are followed. LPA observed the facility shuttle to be equipped with a fire extinguisher which was fully charged. The facility offers a wide variety of activities for the assisted living and memory care units and encourage residents to participate regularly. LPA observed residents participating in group exercise and discussion, individual physical therapy, and attending musical guest performances throughout the visit. Residents were observed to be very engaged in the community and found to have a positive and personable relationship with staff and Executive Director. No deficiencies cited during today's visit.

On 2/25/2025, Licensing Program Analysts (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by Regional Operations Specialist, Alan Fox. The facility currently provides care for 164 residents, 10 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, memory care unit and resident common spaces were inspected. Fire Extinguishers located throughout the inspected portions of the building were found to be charged. Smoke and carbon monoxide detectors and fire safety systems are interconnected. 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 have lighting & appropriate furnishings and bedding items. Residents in the memory care unit that were awake during the inspection were observed 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 activities based on individualized preferences and abilities. LPA observed group karaoke and movies presented to residents along with a variety of activity supplies available. LPA found that staff and resident engagement is well practiced with activity calendars developed on a monthly basis. Residents were found to have a positive and personable relationship with staff. 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 10 residents and found all items to be on file. LPA's found that residents Needs & Service Plans and Medical Assessments were up to date. Upon a spot check of 10 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. LPA will be conducting an annual continuation to further inspect remaining resident living quarters, kitchen and food supply and facility transportation. Executive Director, Fili Igafo's Administrator Certificate 7003332740 is currently pending for renewal but has been received by the department with application received 11/18/2024. LPA requested the following documents be sent to CCL by COB 3/11/2025: LIC 308 Designated Facility Responsibility LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan Liability Insurance No deficiencies cited during the visit.

On 12/27/2024, Licensing Program Analyst, Tobola arrived unannounced for the purpose of conducting a case management to follow up on several incidents reported by the facility. Incident dated 11/11/2024 indicated a resident, (R1) to have boarded onto a bus while they were on an outing with a 1:1 private caregiver from an outside agency. While under private caregiver's supervision, R1 had left on the bus alone and returned to their private family home. R1 was safely returned to the facility with R1's updated services reflecting a new 1:1 care agency. A second incident occurring 11/12/2024, indicated that a resident, (R2) had been observed by staff walking on foot and leaving the property. Staff attempted but were unable to redirect R2, with R2 continuing out into the public. R2 had voluntarily returned back to the facility by bus within approximately 2 hours with no injuries or changes of condition. Upon review of R2's records, LPA found that R2 medical records have contradicting information on whether R2 can leave unassisted or not. Medical assessment indicates R2 is able to leave the facility unassisted but not dated. LPA is requesting for the facility to update R2 medical assessment and provide a copy. Since the incident, the facility has increase R2, level of care, including 1:1 care companion. The facility was found have responded appropriately to prevent further incidents. A third incident dated 11/10/2024, indicated that a resident, (R3) had been provided a shower by two caregivers. R3 was in a shower chair with a seat harness attached. Caregiver staff reported to management that R3 was observed sliding off the shower chair. Caregiver staff responded by slowly assisting/guiding R3 to the floor for reassessment. R3 had sustained a fracture to the femur but the facility was unable to interview the resident and determine any additional findings for how the fracture occurred. LPA was informed that R3 had utilized a hoyer lift and had a history of general weakness in the knees. The facility responded immediately with R3 sent out on medical emergency and returned the same evening. LPA found that the facility responded appropriately to the incident with no determination on how the injury was sustained. Lastly, LPA and Acting Administrator, Fili Igafo discussed a previous request for a hospice waiver increase. At the time of visit, the facility is within the current hospice waiver capacity and will no longer need an increased hospice waiver or exceptions at this time. No deficiencies cited during today's visit.

On 11/7/2024, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of closing an investigation conducted by the Department in regard to a self reported unusual incident report dated 4/21/2024. The incident report indicates that on 4/18/2024, staff checked on resident (R1) in their apartment, finding R1 laying on the floor with a plastic bag over (their) head, tied around (their) neck. Staff determined the resident was unresponsive. According to incident report, the hospice agency was called and then hospice instructed to call 911 due to the “unnatural death.” The Department has reviewed and gathered relevant records including facility incident reports, resident R1 needs & service plans, physician’s reports, daily chart notes and medical records related to this incident and determined the following: On 3/28/2024, R1 had indicated to their family and the facility a refusal to eat and additionally made statements of ending R1’s own life. R1’s family and the facility contacted 911 with R1 sent out for medical attention due to physical pain and suicidal statements. An updated care assessment for R1 had been completed on 3/25/2024 prior to this incident. No further care assessments were conducted after 3/28/2024 when R1 was sent out for medical assessment, or after 3/29/2024 upon R1’s return to the facility. There are no indications of increased status checks or assigning one-on-one care for R1 for preventative measures documented. Based upon the Department’s conducted interview and information gathered with the Health Service Director (S1) the following is indicated: S1 is a Licensed Vocational Nurse (LVN) at Ivy Park. S1 duties are to oversee the care staff, conduct assessments for new and existing residents, review resident’s medication, administer medication to residents, deal with family and resident concerns, and train care staff and medical techs. S1 continues, residents are checked on every one to two hours unless the service plans states that there should be more checks. Staff will not check on a resident if the resident does not want to be checked on. Residents are given an alert pendent when they first arrive at the facility. 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 The pendent allows the resident to call for help when they need it. There are no logs kept when a resident is checked on. When a new resident is admitted to the facility, S1 will conduct an assessment on the resident before they move in. The assessment is done to see what assistance the resident may need with their Activities of Daily Living (ADL) and their mental health status. S1 updates the service plans when a resident has a change in condition. The Department interview with S1 continued regarding R1 level of care and supervision and observations leading to R1’s death. This revealed that S1 was aware of the repeated suicidal statements made by R1 to staff and the hospice nurse. Although S1 admitted they were aware of the change of condition, S1 failed to complete a reappraisal for change in resident’s status and the need for increase status checks of R1 after repeated suicidal statements. S1 additionally indicated that residents are to receive one-on-one after indicating suicidal ideations. S1 however failed to ensure one-on-one care was provided for R1. Lastly, S1 admitted that they should have been more “on top of” R1s situation, provided more frequent checks, and provided R1 additional resources. Based upon the Department’s conducted interview and information gathered with the Executive Director (S2) the following is indicated: S2’s duties are to oversee the facility, manage the lead staff, work on the facilities’ financial, sign off on payroll for the facility, work with the facility nursing director, and approve and review incident reports. S2 continues, residents are checked on one time per shift. Caregivers can check on residents anytime during their shift as long as the resident is checked on before the end of the shift. Residents can refuse to be checked on. Residents are also given an alert pendant that they can press if they need assistance at any point in time when they have an emergency. No log is kept when a resident is checked on. When the facility accepts a new resident, an assessment completed by Health Service Director (S1) to determine the resident needs before they move into the facility. S1 also conducts a mental health evaluation to see if the resident requires memory care. The assessment is also performed to see if the resident is a fit for assisted living or memory care. S1 then reports to the care team what the new resident’s needs and level of care. After the initial assessment is performed, a second assessment is completed two weeks later to see how the resident is adjusting to the facility and determine any updated needs. A reassessment is performed every six months or when a resident has a change of condition. The facility considers a change of condition when there is a change in the resident’s baseline behavior or mental health status. Continued onto LIC899-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 Department interview with S2 continued regarding R1 level of care and supervision and observations leading to R1’s death . S2 indicated that when a resident states that they are going to harm themselves, Health Service Director, S1 is notified, S1 speaks with the resident, and notifies the resident’s Primary Care Provider and responsible party. S1 is to remove a ny harmful objects from the resident’s apartment if necessary and update the resident’s service plan to more frequent status checks every two hours. S1 is also responsible for making a recommendation to the family for the resident to receive one-on-one care paid for by the family. The facility can provide the one-on-one care to the family at an additional cost or with the option to pay for an outside company to and provide the additional care. If a resident has suicidal thoughts or attempts, they will be placed on increased status checks and will be checked on every two hours. The facility staff will also encourage the resident to socialize in the community more with the other residents. S2 was not aware of R1 having any mental health concerns when R1 arrived at Ivy Park. However, S2 was aware that R1 was exhibiting suicidal ideations with R1’s family calling 911 in March 2024 due to R1 stating that they were going to stop eating and made statement of wanting to commit suicide. The facility responded by sending R1 to the hospital for an evaluation. S2 stated that they required S1 to update R1’s needs and services plan upon return. Additionally, S2 addressed to S1 and R1’s family that R1 needed to be placed on hospice. S2 stated that R1’s care plan was updated to have assistance with his ADL’s but was not certain if S1 updated R1’s plan to have increased checks. Based upon document review it was found that R1 had bend sent out to the hospital for evaluation on 3/28/2024 and returned 3/29/2024. Record review found that the most updated needs and service plan was dated 3/25/2024 and input on 3/27/2024, prior to R1 initially being sent out for hospital. Interview continues indicating S2 was first aware of R1’s suicidal statement in March 2024. R1 was provided room checks every two hours before R1 made suicidal statements. Room checks were not updated and with R1 still provided room checks every two hours after R1 made his suicidal statements. S2 discussed one-on-one care with R1’s family but R1 never received the one-on-one care. On 04/18/2024, S2 indicated that Health Service Director (S1) and hospice nurse discussed R1 again stating that they wanted to commit suicide. The hospice nurse removed a pair of scissors from R1’s room and S2 held a follow up discussion with S1 regarding the one-on-one care for R1. S1 addressed to S2 that they did not follow back up with the family regarding the one-on-one care. On the same date 4/18/2024, R1 was found in their bedroom deceased. 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 S2 stated that after R1 made initial statements about taking their own life, the facility should have updated R1’s needs and services plan to include increased checks. S2 was not aware of why the increased checks were not implemented. S2 admitted that R1’s death could have been prevented if R1 was given one-on-one care sooner and was provided more supervision. The Department additionally conducted interviews with several caregiving staff but found information and statements to be inconsistent with investigation. An immediate civil penalty is being assessed today in the amount of $500 for a violation that resulted in the sickness or injury of a resident in care. Additional Civil Penalty pending review per H&S Code Section 1569.49. Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and the Health and Safety Code. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Appeal Rights Given.

Complaint alleges facility staff are not conducting planned activities with residents. Based upon tours of the facility memory care unit LPA observed residents engaging with staff and outside parties with various activities throughout the day. The activities observed included group exercise, pet therapy, music and yoga through multiple visits in accordance with facility activity calendar. Due to a lack of corroborating evidence, the allegation is found to be unsubstantiated. A finding that the complaint allegations, facility staff are locking residents in their bedrooms & facility staff are not conducting planned activities with residents are 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.

Regarding the allegation, that staff did not respond to resident’s call button in a timely manner, the Department found through a review of the call button response log that on several occasions, facility staff have taken up to a total of 289 minutes to respond to call buttons. Furthermore, the LPAs learned that within the last 2 weeks, there have been a total of 16 residents who waited more than 30 minutes for assistance. Regarding this allegation, the preponderance of evidence has been met, and the allegation is SUBSTANTIATED. The Department has investigated the above allegations of a possible violation of a resident’s personal rights. Based on the investigation, the preponderance of evidence standard has been met, therefore the above allegations are determined to be SUBSTANTIATED. The deficiencies cited on the following pages are in violation of the California Code of Regulations, Title 22, Division 6, Chapter 8, Article 7: Personnel Requirements-General. An exit interview was conducted. This report was reviewed with Fili Igafo, Executive Director and a copy of the report along with Appeal Rights were left 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 Regarding the allegation, that the resident was left on the floor for an extended period of time, LPAs interviewed staff and asked but were not able to procure a copy of the call button response times. Due to a lack of evidence, this allegation is UNSUBSTANTIATED. The department has investigated the above allegations that staff did not observe resident’s change of health conditions or reassess resident’s care plan. The allegations are UNSUBSTANTIATED meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted. This report was reviewed with Fili Igafo, Executive Director and a copy of the report left at the facility.

On May 14, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility to deliver an Amended complaint investigation report from January 4, 2024. LPA Calandra was greeted by Fili Igafo, Executive Director and explained the purpose of the visit. The report was Amended due to new information being discovered through the course of the investigation LPA Calandra obtained the facility's copy of the report from January 4, 2024. This report was reviewed with Executive Director, Fili Igafo and a copy of the report left at the facility.

On April 23, 2024 at 9:30 AM, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct an unannounced Case Management-Health and Safety check in regards to an incident report received by the department on April 22, 2024 regarding the death of a resident. LPA Calandra was greeted by Alan Fox, Regional Operations Specialist and explained the purpose of the visit. LPA Calandra requested and received the following documents: -Resident's LIC 602-Physician's report -Annual Needs and Service Plan or Care Plan -Admissions Agreement - Progress notes - Resident's Medication Records - Doctor's orders - Resident Record - Hospice Notes No deficiencies were cited during today's visit. This report was reviewed with Alan Fox, Regional Operations Specialist and a copy of the report left at the facility.

On February 15, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility at 9:00 AM to continue the Annual 1-year required inspection. LPA Calandra met with Michelle Herman and explained the purpose of his visit. Faimafili Igafo, Executive Director arrived later during the visit. LPA Calandra reviewed 5 resident records. All were observed to be complete. LPA Calandra interviewed 3 residents and 3 staff. No deficiencies were cited during today's visit. The report was reviewed with Faimafili Igafo, Executive Director and a copy of the report left at the facility.

On July 5, 2023 Licensing Program Analysts (LPA) Murial Han conducted an unannounced case management visit to deliver the findings in reference to complaint # 14-AS-20230425173240. LPA met with administrator and explained the purpose of the visit. During the course of the investigation, Resident 1 (R1) stated that early morning of 4/20/2023 around 5-6AM, R1's roommate resident #2 (R2) fell. R1 pressed the call cords in the room and after a long period of waiting, R1 went outside of the room pleading for assistance, however, no one was available. Therefore, R1 went back to the room and assisted R2 off of the floor, back into bed. According to the documentation provided by the facility, on 4/20/2023, it did not indicate that facility staff provided assistance to R2 after the fall. Based on the complaint investigation, on the day of the fall, it took facility staff 205 minutes and 46 seconds to respond to R1's call cord and no one was available to assist R2 back to bed after fall which resulted R1 assisting R2 off of the floor and back to bed. Deficient is cited under California Health and Safety Code on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. Report was discussed and reviewed with administrator. A copy of this report and the Appeal Rights is provided.