South County Retirement Home Inc.

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management - Legal/Non-compliance visit and met with Administrator (ADM) Samuel Apostol. The purpose of the visit is to ensure the facility is adhering to the Compliance Plan submitted to Community Care Licensing (CCL) after a non-compliance meeting held on February 8, 2024. During visit, LPA Marrufo toured the facility hallways, common areas, resident bedrooms, bathrooms, and outdoor areas. One bedroom was undergoing renovations during visit. ADM stated that the facility has received a grant and is renovating each room one at a time. All fire exit routes were free and clear of obstruction. LPA observed signs posted next to the resident bedroom doors for the residents who are a fall risk. Fly traps were observed next to exit doors, inside the resident bedrooms, smoking areas, common areas, and hallways. The facility protocol for contacting 911 and signs instructing staff what to do if a resident has a fall were posted throughout the facility. LPA randomly reviewed 3 resident files, which included but were not limited to: physicians report, needs and services plan, and admission agreement. 3 staff files were randomly reviewed and the staff training files were up-to-date. LPA observed facility maintenance log. LPA observed the fall risk log is completed daily and every 2 hours, which contains the list of residents who are a fall risk and incontinent. No deficiencies were cited as per California Code of Regulations, Title 22. This report was reviewed with Administrator Samuel Apostol and a copy of this report was provided.

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection, and met with House Manager (HM) Ivonne Chavez. LPA reviewed 5 resident files and 4 staff files. LPA observed licensee, Administrator Certificate, and personal rights posters at the facility. LPA toured the facility with HM inside and out. LPA inspected living room, dinning room, kitchen offices, 1 staff restroom, 2 shower rooms, TV room, and 23 resident rooms in the facility. Each resident room has its own restroom. Two days perishable foods and seven day nonperishable foods were observed sufficient. Room temperature was observed at 69 degree F, hot water temperature was observed at 105 degree F. The temperature of the freezer was observed at 0 degree F and the temperature of the refrigerator was observed at 37 degree F. Medication room, laundry room, kitchen were observed locked. The facility was equipped with fire alarm, smoke and carbon monoxide detectors. Carbon monoxide detector was tested, and was working. Fire extinguisher was serviced on 5/20/2025. The fire alarm system test report dated 12/15/2025 was observed. First aid box was observed in the facility. The facility has emergency lighting system. The last time the facility conducted the fire drill was on 12/15/2025. Front yard and backyard were inspected. There was no obstruction to block the walkways. One storage room with food and refrigerator was observed at backyard. No citation noted for today's visit. Exit interview was conducted with HM. This report was provided to HM for signature. A copy of this report was provided to HM.

On November 19, 2025 at 8:45am, Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Case Management - Incident visit in regards to an Incident Report the Department received on 11/18/2025. LPA met with Administrator Sam Apostol and stated the purpose of the visit. On 11/18/2025, the Department received an LIC 624 Incident Report stating on 11/17/2025 resident R1 was found unconscious and staff called 911 in response and R1 was transported to the hospital. Administrator Sam Apostol was informed R1 passed away at the hospital the same day. During today's visit, LPA Rai received information from Administrator, Sam Apostol and two staff members. LPA Rai obtained a copy of R1's ID and Emergency Information and LPA Rai received copies of R1's Appraisal/Needs and Services Plan and R1's Physician's Report. At this time, LPA Rai determined this case management needs further investigation. Administrator Sam Apostol will provide a copy of R1's Death Report when it becomes available. This report was reviewed with Administrator Sam Apostol and a copy of the report was provided.

Based on document review and interviews although the allegation that facility staff dispensing medication is under the age of 18 years old could have happened the preponderance of evidence have not been met and therefore the allegation is unsubstantiated . No deficiencies were cited during today's visit based on the California Code of Regulations (CCR) Title 22. An exit interview was conducted with Licensee/Administrator Samuel Apostol and a copy of the report was provided. End of Report page 4 of 4

Based on the document review, R1 does not take his/her medication at home resulting to a severe schizoaffective disorder, bipolar and catatonia. R1 has history of mental illness, R1 is able to ambulate and is able to leave the facility unassisted as stated on his/her physician's report (LIC 602). R1 has mild cognitive disorder. R1 was admitted to the hospital from 02/06/25 and was discharged on 07/17/25. R1 was admitted due to history of odd behaviors and changing cognition. R1 moved to the facility after discharged from the hospital. Based on observation. LPA observed at the time of the visit on on 10/03/25, that R1 called a family member and alleges that he/she was being maltreated. Family called the facility and ADM assured R1s family member that R1 is unharmed. At the same time R1 called his/her case manager from Telecare and stated that there is an emergency happening at the facility. R1s CM called the facility to confirm, ADM assured CM that R1 is unharmed and no emergency or EMT personnel is at the facility. R1 approached LPA and stated to LPA that he/she was beaten on his/her arms, shoulder, body. LPA did not observed any bruising on R1s arms or legs. R1 followed LPA while LPA was conducting inspection of the facility on 10/03/25. LPA did not observed R1 to be in pain. Based on interview, observation and document review, the department has investigated the complaint alleging that, staff did not provide adequate supervision resulting in resident sexually abusing another resident. 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. No deficiencies were cited during today's visit based on the California Code of Regulation (CCR) Title 22. An exit interview was conducted with LIC/ADM Samuel Apostol and a copy of the report was provided. Page 2 of 2 end of report

Resident (R1) was interviewed who stated that he/she only came to the facility with a suitcase, clothes, and a cane. R1 states he/she did not come to the facility with any other item to include a leg brace. R1 states that he/she only came with a few clothes but his/her family member and facility staff bought extra clothes for him/her. R1 states that he/she has 2 cell phones and a phone charger. R1 stated that his/her family member bought clothes for him/her but all the clothes are locked in the washing machine. 2 staff members were interview. Based on staff interviews, R1 did not come to the facility with a leg brace. It was stated that R1's previous facility did not send all his/her personal items and R1 only came with the clothes he/she was wearing, a guitar and a cane. Based on observation of R1's bedroom, LPA Kabariti observed R1's closet has at least 5 pairs of pants, at least 6 shirts, socks and briefs. LPA Kabariti observed additional clothing items on the floor next to R1's bed, 2 cell phones, a charger which R1 states he/she uses for his/her cell phone, and a walker. The review of records shows that R1 was admitted to the facility in July 2024. When R1 moved into the facility items that were safeguarded included a cell phone and clothing items but the leg brace and cell phone charger was not listed as part of safeguard items. LPA Kabariti entered into the laundry room with staff and observed the washer and dryers were in good repair. LPA observed the washers and dryers were in use. It was stated that all resident clothing items are labeled with the resident's name, which LPA observed. The office manager and Administrator states that the resident's clothing items are washed daily and as needed. LPA observed the laundry room is locked and only accessible to staff. It was also alleged that the facility staff does not accord resident with privacy during showers . Based on the reporting party (RP), it was stated that R1 has a health condition where he/she has difficulty walking and cannot stand for a long period of time. It was stated that R1 did not like that staff were sitting in the shower with him/her. Page 2 of 3. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Based on interview with R1, it was stated that he/she has to ask permission to use the shower because the shower rooms are locked. R1 stated that before, there used to be a staff who sat in the shower room while R1 was showering and R1 did not like that. R1 states that now, the staff waits outside for him/her to finishing showering. R1 states they wait outside for him/her in case R1 has a fall. Based on record review, R1 does have the capacity for self-care to include bathing, dressing and grooming, but has a condition that affects his/her movement and coordination. 2 staff members interviewed stated that because they are an assisted living facility the staff supervise the residents during shower for their safety, such as a fall. It was stated that the staff assist R1 in the shower because they are afraid that R1 will fall due to his/her health condition. S1 and S2 stated that if a resident does not feel comfortable with the staff assisting them in the shower and they are able, the staff would do a body check of the resident to ensure there are no changes in condition, and then step outside and wait for the resident to finish showering. The Department has investigated the above allegations. Based on interview, record review and observation the above allegations are unfounded, meaning the allegations are false, could not have happened, and/or is without reasonable basis. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator, Sam Apostol and Office Manager, Ivonne Chavez and a copy of the report was provided. Page 3 of 3.

Licensing Program Analysts (LPA) Christine Kabariti arrived unannounced to conduct a case management - legal/non-compliance visit. LPA met with Lead MedTech Julianna "Julie" Garcia, Administrator Sam Apostol and Office Manager Ivonne Chavez. The purpose of the visit is to ensure the facility is adhering to the Compliance Plan submitted to Community Care Licensing (CCL) after a non-compliance meeting held on February 8, 2024. During visit, LPA toured the facility with staff to include all the resident bedrooms, hallways, common areas, storage and exterior. It was observed the facility is currently undergoing renovations. Staff stated that the renovations are starting in the resident bedrooms but only one bedroom is being renovated at a time to minimize the impact to the residents. All fire exit routes were free and clear of obstruction. LPA observed signs posted next to the resident bedroom doors for the residents who are a fall risk. Fly traps observed next to exit doors, inside the resident bedrooms, smoking areas, common areas and hallways. Facility protocol for contacting 911 and what to do if a resident has a fall signs posted throughout the facility. LPA observed the facility was well maintained. Page 1 of 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 LPA randomly reviewed 3 resident files, which included but not limited to; physicians report, needs and services plan, and admission agreement. 3 staff files were randomly reviewed and the staff training files were up-to-date. LPA observed facility maintenance log. LPA observed the fall risk log are completed daily and every 2 hours, which contains the list of resident who are a fall risk and incontinent. During visit, LPA obtained the facility's request letter to increase capacity, LIC200, and the facility sketch. No deficiencies cited per California Code of Regulations, Title 22. This report was reviewed with Administrator Samuel Apostol and Office Manager Ivonne Chavez a copy of the report was provided. Page 2 of 2.

R1 was admitted to the facility on 03/03/2025. 3 residents were interviewed. Based on interview, 1 out of 3 resident stated to have helped R1 clean his/her bed with a witness (W1) because R1 and R1’s bed was soiled. This resident stated to have voluntarily cleaned R1’s bed because the staff was taking too long to come to the room. This resident denied staff checking on the residents regularly and in the morning. 2 out of 3 residents interviewed stated that the staff check in on the residents daily in the morning and throughout the day, and denied observing other residents left in soiled adult briefs. Based on interview with witness (W1), W1 observed R1 laying in bed soaked full of urine about 3 times since he/she has visited the facility. W1 was unable to recall the dates of observation. W1 stated that he/she visits the facility daily at 10:00am and around 2:00pm. It was stated that he/she has observed R1 left laying in his/her urine around 10:00am and when he/she returned to the facility at 2:00pm. W1 states that when he/she observed R1 laying in bed soaked in urine, W1 did not tell the staff. W1 states that there was always staff in the hallways and assumed they’d check in on R1. W1 denied observing staff help R1. The review of R1’s pre-placement appraisal notes that R1 is incontinent and did not need help with toileting but needs help with bathing and personal hygiene. 6 staff members were interviewed. Based on staff interview, it was stated that R1 came from an independent living home. The facility was informed that R1 was able to change his/her own adult briefs. It was stated that when R1 first moved in, R1 refused staff assistance to change his/her adult brief and any assistance in the bathroom. Staff stated that in beginning R1 needed to be constantly reminded to use the bathroom and change his/her adult briefs. Staff members stated that they ensure R1 is checked and asked every 2 hours to go to the bathroom and to change his/her adult brief. Page 2 of 3. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 The review of facility records shows that the facility noted on 03/12/2025 that R1 woke up with a wet bed and heavy adult brief but did not want to change his/her adult brief. Staff asked R1 to return to his/her room and change his/her adult brief. On 03/16/2025, a staff communication was noted to make sure R1 changed his/her adult brief every 2 hours and to shower if necessary. Based on observation on 04/11/2025, R1 was not observed soiled around 10:00am and 11:00am. R1’s bedroom did not have an odor of urine and feces. The Department has investigated the above allegation. Based on interview, record review and observation the above allegation is unsubstantiated. An unsubstantiated finding indicates that although the allegation may have happened and/or is valid there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator(ADM) Samuel Apostol and Office Manager (OM) Ivonne Chavez and a copy of the report was provided. Page 3 of 3.

Licensing Program Analysts (LPA) Christine Kabariti arrived unannounced to conduct a case management - legal/non-compliance visit. LPA met with Administrator(ADM) Samuel Apostol and Office Manager (OM) Ivonne Chavez . The purpose of the visit is to ensure the facility is adhering to the Compliance Plan submitted to Community Care Licensing (CCL) after a non-compliance meeting held on February 8, 2024. During visit, LPA toured the facility with OM to include all the resident bedrooms, hallways, common areas, storage and exterior. All fire exit routes were free and clear of obstruction. LPA observed signs posted next to the resident bedroom doors for the residents who are a fall risk. Fly traps observed next to exit doors, inside the resident bedrooms, smoking areas, common areas and hallways. Facility protocol for contacting 911 and what to do if a resident has a fall signs posted throughout the facility. LPA observed the facility was well-maintained. LPA randomly reviewed 3 resident files, which included but not limited to; physicians report, needs and services plan, and admission agreement. 3 staff files were randomly reviewed and the staff training files were up-to-date. LPA observed facility maintenance log. LPA observed the fall risk log are completed daily and every 2 hours, which contains the list of resident who are a fall risk and incontinent. No deficiencies cited per California Code of Regulations, Title 22. This report was reviewed with Administrator Samuel Apostol and Office Manager Ivonne Chavez a copy of the report was provided.

The Administrator stated that R1 does not like to have a roommate, however, is unable to pay for the cost of a private bedroom. Administrator stated that R1 was aware that his/her bedroom would be a shared bedroom and consented to it. It was stated that due to conflicts with R1’s previous roommate, they thought R2 would be a good fit to be R1’s roommate Administrator stated to address R1’s sleep concerns they have provided R1 was ear plugs and reached out to R1’s case manager. It was stated that R1 also had headphone that he/she uses during the night. It was stated that due to the constant roommate switches, the facility has challenges in finding another roommate who would be compatible with R1’s needs. It was stated that it was also unfair to move residents around who are already settled and comfortable in their rooms. Administrator denied R1 reaching out to request for a specific roommate. Based on interview with R1, it was stated that R1 had a preference for which roommate he/she preferred. R1 stated that he/she did not talk to the Administrator and staff regarding his/her roommate request. R1 stated that he/she found ear plugs inside his/her room on 04/30/2025 but R1 didn’t need that as R1 was already using noise canceling headphones. R1 states that even with the use of noise canceling headphone, R2’s snoring was too loud that he/she can hear it through the headphones resulting in sleep deprivation. R1 did not want to inform the Administrator of his/her request and consented for LPA Kabariti to inform the Administrator regarding his/her roommate request. On 05/01/2025, the Administrator switched R1’s roommate to the preferred roommate R1 requested. Based on record review, it was stated that R1 and R3 both agreed to share a room. The Department has investigated the above allegation. Based on interview and record review, the above allegation is unfounded meaning the allegation is false, could not have happened and/or is without a reasonable basis. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator(ADM) Samuel Apostol and Office Manager (OM) Ivonne Chavez and a copy of the report was provided.

It was alleged that when resident (R1) returned from the hospital, R1’s room looked different than how he/she left it. It was alleged that staff went through resident (R1)’s bedroom, threw R1’s shoes over the fence outside of R1’s bedroom, and threw away R1’s dry foods inside his/her bedroom. It was also alleged that staff had taken R1’s jacket and new shoes. A witness (W1) was interviewed. Based on interview, it was stated that R1 had only reported that his/her items were missing to W1, but denied observing staff remove these items from R1’s bedroom. W1 was unable to provide proof that the items were taken from the staff. 3 staff members were interviewed. Based on staff interview, it was stated that on 04/10/2025 staff needed to remove items from R1’s bedroom as staff observed expired and molded food inside R1’s personal refrigerator that was purchased by the Administrator. It was stated that R1 also had items that are not allowed to be stored in the resident rooms to include cleaning supplies, scissors, and tools. For the resident’s safety, staff talked to R1 about the items that needs to be removed in which R1 began to get verbally aggressive towards the staff. Due to R1’s aggression, law enforcement was called and R1 was transported to the hospital to be evaluated. Staff stated that the only items that was removed was the dry foods, expired food inside R1’s personal refrigerator, chemicals and sharp objects. 3 out of 3 staff interviewed denied removing any clothing items from R1’s bedroom to include R1’s shoes and jackets. 5 residents were interviewed. Based on interview, 5 out of 5 residents could not prove that staff removed items from their bedroom without any good reason. Page 2 of 3. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Based on interview with R1’s former roommate, R2 observed shoes outside their bedroom but was unsure how the shoes got there. R2 later found out it was R1’s shoes. R2 was unsure how the shoes got outside but states that R1 was upset and stated that staff put them there. R2 denied observing staff throw R1’s shoes outside and denied observing staff throw R1’s clothing items away. When staff questioned R1 about the shoes that was observed over the fence, it was stated that R1 admitted to throwing his/her shoes over the fence and later apologized to staff. Based on record review, R1 only safeguarded 1 shoe, 2 shirts, 2 shorts, 2 socks, 1 book, and 3 pairs of underwear. No additional items were safeguarded on the form to include a jacket and additional pairs of shoes. R1’s records note that on 04/10/2025, staff observed expired and molded food inside R1’s personal refrigerator. Staff talked to R1 who started to get aggressive towards the staff for not letting staff clean and throw away items. 911 was called due to R1’s aggressive behavior towards the staff. There was no indication that R1's clothing items were removed to include shoes and a jacket. The Department has investigated the above allegation. Based on interview, record review and observation the above allegation is unfounded meaning the allegation is false, could not have happened, and/or is without a reasonable basis. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator, Samuel Apostol and Office Manager, Ivonne Chavez and a copy of the report was provided. Page 3 of 3.

Licensing Program Analysts (LPAs) Christine Kabariti and Manuel Monter arrived unannounced to conduct a case management - legal/non-compliance visit. LPAs met with Administrator(ADM) Samuel Apostol. The purpose of the visit is to ensure the facility is adhering to the Compliance Plan submitted to Community Care Licensing (CCL) after a non-compliance meeting held on February 8, 2024. During visit, LPAs toured the facility with ADM and staff to include all the resident bedrooms, shower room, hallways, common areas, beauty room, and exterior. All fire exit routes were free and clear of obstruction. LPAs observed signs for the residents who are a fall risk. LPAs observed fly traps in the backyard smoking area and hallways. During the tour, LPAs observed facility protocol for contacting 911 and what to do if a resident has a fall throughout the facility. LPAs observed staff members cleaning the facility. LPA randomly reviewed 3 resident files, which included but not limited to; physicians report, needs and services plan, and admission agreement. LPAs also reviewed staff training files were up-to-date. LPAs observed facility maintenance log and the 2 hourly check log. LPAs observed the fall risk log, which contains the list of resident who are a fall risk. No deficiencies cited per California Code of Regulations, Title 22. This report was reviewed with Administrator Samuel Apostol and a copy of the report was provided.

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced Case Management to conduct a Non-Compliance Plan Visit. LPA met with Administrator(ADM) Samuel Apostol and stated the purpose of today's visit. The purpose of the visit is to ensure the facility is adhering to the Compliance Plan submitted to Community Care Licensing (CCL) after an informal meeting held on February 8, 2024. During visit, LPA toured the facility with ADM, inside and out, including the beauty room. All fire exit routes were free and clear of obstruction. LPA observed signs for the residents who are a fall risk. LPA observed fly traps in the backyard smoking area. During the tour, LPA observed facility protocol for contacting 911 and what to do if a resident has a fall throughout the facility. LPA observed a staff member doing the status check rounds. LPA randomly reviewed 3 resident files, which included but not limited to; physicians report, needs and services plan, and admission agreement. LPA also reviewed staff training files and facility file. LPA observed facility maintenance log and the 2 hourly check log. LPA observed the fall risk log, which contains the list of resident who are a fall risk. No deficiencies cited per California Code of Regulations, Title 22. This report was reviewed with Administrator Samuel Apostol and a copy of the report was provided.

LPA Monter interviewed Staff S1-S5. 5 Out of 5 staff interviewed stated staff do not withhold residents’ medications. 5 Out of 5 staff interviewed stated residents’ medications are being administered daily. LPA interviewed ADM. ADM stated facility staff does not withhold residents’ medications. ADM stated residents’ medications are being administered. On November 12, 2024, LPA Monter interviewed R1. R1 stated the facility did not administer his/her medication, such as his/her antibiotic medication, because he/she knew about staff S1’s Infidelity. R1 stated he/she does not know the name of the medications he/she wasn’t given. R1 stated he/she doesn’t remember when the medication was not administered either. On November 15, 2024, LPA Monter interviewed residents R7-R12. 5 Out of 6 residents interviewed (R7-R11) stated they get their medication daily and staff does not withhold their medications. 1 Out of 6 residents interviewed (R12), stated he/she does not want to answer LPA's questions and declined to be interviewed. Based on a review of R1’s Physicians Report, dated September 22, 2014, and Needs and services plan, dated February 5, 2023, states R1 experiences auditory and visual hallucinations. The Physicians Report also states R1 is paranoid that something is trying to get him/her. Based on a review of R1’s Medication Administration Log, the form shows R1’s medications were administered. Further review of R1’s medication administration record showed R1’s antibiotics were administered as well. The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED , meaning that the allegations were false, could not have happened and/or are without a reasonable basis. Page 2 Out of 4. 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 Facility staff selling resident's medication for financial gain On August 26, 2024, the Department received a complaint alleging staff selling resident's medication for financial gain. It has been alleged that R1’s medications were sold for financial gain. On September 5, 2024, Licensing Program Analyst Manuel Monter interviewed Staff S1-S5. 5 Out of 5 staff interviewed stated staff do not sell residents medications. LPA Monter interviewed residents R2-R6. 5 Out of 5 Residents interviewed stated they get their medication everyday and staff do not withhold their medication. On November 12, 2024, LPA Monter interviewed R1. R1 stated the facility did not administer his/her medication, such as his/her antibiotic medication, because he/she knew about staff S1’s Infidelity. R1 stated he/she does not know the name of the medications he/she wasn’t given. R1 stated he/she doesn’t remember when the medication was not administered either. R1 stated he/she overheard S1 talking to a family member on the phone discussing selling R1’s medications. R1 stated he/she does not remember when this phone call took place. On November 15, 2024, LPA Monter interviewed residents R7-R12. 5 Out of 6 residents interviewed (R7-R11) stated they get their medication daily and staff does not withhold their medications. 1 Out of 6 residents interviewed (R12), stated he/she does not want to answer LPA's questions and declined to be interviewed. Based on a review of R1’s Physicians Report, dated September 22, 2014, and Needs and services plan, dated February 5, 2023, states R1 experiences auditory and visual hallucinations. The Physicians Report also states R1 is paranoid that something is trying to get him/her. Page 3 Out of 4. 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 Based on a review of R1’s Medication Administration Log, the form states R1’s medications were administered. Further review of R1’s medication administration record showed R1’s antibiotics were administered as well. The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED , meaning that the allegations were false, could not have happened and/or are without a reasonable basis. Page 4 Out of 4. END OF REPORT.

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced Case Management to conduct a Non-Compliance Plan Visit. LPA met with Administrator(ADM) Samuel Apostol and stated the purpose of today's visit. The purpose of the visit is to ensure the facility is adhering to the Compliance Plan submitted to Community Care Licensing (CCL) after an informal meeting held on February 8, 2024. During visit, LPA toured the facility with ADM, inside and out. All fire exit routes were free and clear of obstruction. LPA observed signs for the residents who are a fall risk. LPA observed fly traps in the backyard smoking area. During the tour, LPA observed facility protocol for contacting 911 and what to do if a resident has a fall throughout the facility. While touring the facility, LPA observed a shed in the backyard. ADM stated the shed does have electricity and they contacted an electrician to set up the electrical. LPA requested a copy of the work order. While touring the front yard of the home, LPA observed a new gazebo in the garden area. LPA reviewed 2 resident files, which included but not limited to; physicians report, needs and services plan, and admission agreement. LPA also reviewed staff training files and facility file. LPA observed facility maintenance log and the 2 hourly check log. LPA observed the fall risk log, which contains the list of resident who are a fall risk. No deficiencies cited per California Code of Regulations, Title 22. This report was reviewed with Administrator Samuel Apostol and a copy of the report was provided.

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced Case Management to conduct a Non-Compliance Plan Visit. LPA met with Administrator(ADM) Samuel Apostol and stated the purpose of today's visit. The purpose of the visit is to ensure the facility is adhering to the Compliance Plan submitted to Community Care Licensing (CCL) after an informal meeting held on 02/08/2024. During visit, LPA toured the facility with ADM, inside and out. All fire exit routes were free and clear of obstruction. LPA observed signs for the residents who are a fall risk. LPA observed fly traps in the backyard smoking area. During the tour, LPA observed facility protocol for contacting 911 and what to do if a resident has a fall throughout the facility. LPA reviewed 2 resident files, which included but not limited to; physicians report, needs and services plan, and admission agreement. LPA also reviewed staff training files and facility file. LPA observed facility maintenance log and the 2 hourly check log. LPA observed the fall risk log, which contains the list of resident who are a fall risk. No deficiencies cited per California Code of Regulations, Title 22. This report was reviewed with Administrator Samuel Apostol and a copy of the report was provided.

Resident R1 stated R2 came running and hit R1. R1 stated R2 had pushed him/her and hit him/her on the head, shoulder, and spine. Resident R2 stated he/she started walking towards the home to go inside. R2 stated R1 then got in front of R1 and they bumped into each other. R2 stated when R1 bumped into R2, R1 fell down. R2 denies pushing R1. On May 16, 2024 and June 5, 2024, LPA interviewed 3 staff (S1-S3) and facility ADM. 3 Out of 3 staff and facility ADM stated they did not witness the R2 pushing R1. ADM stated the alleged altercation occurred during dinner time, while he was in his office. Staff S1 stated he/she was in the medication room prepare medications for the 5pm pass out. Staff S2 stated he/she was in the kitchen preparing the food for the second seating and was keeping an eye on dinning residents. S3 stated he/she was in the laundry room. All staff interviewed stated they did not hear residents R1 or R2 yelling, arguing or screaming prior to the alleged incident. ADM stated he was informed by R1 that he/she was pushed by R2. ADM stated he assessed the resident and called 911, following his fall protocol. ADM stated R1 had returned from the hospital the same day with no new orders. Based on record review, there is no history of physical altercations between resident R1 and R2. Although R1 falling is a fact, based on interviews conducted, this incident was caused by R1 and R2 bumping into each other, was an accident. As this incident happened in a split moment, with no prior audio ques, facility staff could not feasibly prevent resident R2 from accidentally bumping into R1. Facility staff also responded immediately once they became aware of the alleged incident and sought timely medical attention for R1, per facility policies. Page 2 Out of 3. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED , meaning that the allegations were false, could not have happened and/or are without a reasonable basis. No deficiencies cited, an exit interview conducted with Administrator, Sam Apostol and a copy of the report was provided. END OF REPORT. Page 3 Out of 3.

Licensing Program Analyst (LPA) Manuel Monter arrived unannounced to conduct a case management to amend a complaint investigation LIC9099 and LIC9099-C issued on April 26, 2024 (26-AS-20240419161735) due to additional information. LPA met with Administrator Samuel Apostol. No deficiencies cited. A copy of the report was provided to Administrator Samuel Apostol.

On May 2, 2024, LPA interviewed 6 staff, (S1-S6). All staff interviewed stated they give residents privacy when they are meeting with their case managers. S1 & S2 stated the front yard gazebo is sometimes used by staff to eat their lunch, but if a case manager is already there, the staff will give them privacy. S6 stated he/she and S4 were already eating lunch when R1 arrived with his/her case manager. Staff Forced Resident to Sign Documents On April 19, 2024 the department received a complaint alleging Staff forced resident to sign documents On April 26, 2024, LPA's interviewed residents R1-R10. 8 Out of 10 (R2-R3, R5-R10) residents interviewed stated the facility did not force them to sign documents. R4 stated he/she did not know if he/she was forced to sign documents. R1 stated he/she was forced to sign documents, but doesn't know what he/she was forced to sign or when he/she was forced to sign the documents. On April 26 & May 2, 2024, 2024, LPA interviewed facility ADM. ADM stated the facility does not force residents to sign documents. ADM stated if a resident does not want to sign, then they will write, "refused to sign." ADM stated he will then inform their case manager that the resident is refusing to sign. ADM confirmed that R1's social worker was present when R1 was admitted. ADM stated R1's social worker was explaining to R1 what was being signed. On May 2, 2024, LPA interviewed R1. LPA showed R1 his/her resident file. LPA showed R1 the signed documents and R1 confirmed those were the documents he/she signed, this included R1's Identification and emergency information form, Personal Rights, Admission Agreement, Photo release, House rules, Personal Property form, Consent for Emergency Medical Treatment & Release of Client medical information form. R1 stated he/she does not like to sign forms because he/she stated once she signs, she's responsible. R1 confirmed that he/she was not forced or coerced but the staff. R1 stated she likes living at the facility and likes her roommate, R1 confirmed his/her social worker was with him/her when he/she signed. Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED . An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. No deficiencies cited, an exit interview conducted with Administrator, Sam Apostol and a copy of the report was provided. END OF REPORT.

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced Case Management to conduct a Non-Compliance Plan Visit. LPA met with Administrator(ADM) Samuel Apostol and stated the purpose of today's visit. The purpose of the visit is to ensure the facility is adhering to the Compliance Plan submitted to Community Care Licensing (CCL) after an informal meeting held on 02/08/2024. During visit, LPA toured the facility with ADM, inside and out. All fire exit routes were free and clear of obstruction. LPA observed signs for the residents who are a fall risk. During the tour, LPA observed facility protocol for contacting 911 and what to do if a resident has a fall throughout the facility. LPA reviewed 2 resident files, which included but not limited to; physicians report, needs and services plan, and admission agreement. LPA also reviewed staff training files and facility file. LPA observed facility maintenance log and the 2 hourly check log. LPA observed the fall risk log, which contains the list of resident who are a fall risk. No deficiencies cited per California Code of Regulations, Title 22. This report was reviewed with Administrator Samuel Apostol and a copy of the report was provided.

On February 21, 2024, Licensing Program Analyst, Manuel Monter conducted an unannounced case management visit. The purpose of this case management is regarding an incident that occurred on July 2, 2023, where R1 grabbed a fork and stabbed R2 on the forehead. On July 28, 2023, the Department received an incident report regarding resident R1 assaulting resident R2 around 12pm. R2 was taken to the hospital and has returned to the facility. As a result, R1 was arrested. On August 01, 2023, the Department conducted a preliminary case management visit to get residents R1 and R2’s documents. LPA also requested facility staff schedule and progress notes. On August 28,2023 the Department interviewed resident R2, Staff S1-S3, and Administrator (ADM) regarding the altercation that occurred on July 2, 2023. Based on the Department’s investigation, while staff S1 was about to serve food to the residents, S1 noticed that resident R1 and R2 were arguing at the dining area during a mealtime. S1 saw that R1 got a fork and stabbed R2 on the forehead. S1 stated that ADM was close by and grabbed R1 by the hand that was holding the fork to prevent the assault from continuing. S1 was also grabbing R1’s other hand at the same time. S1 stated staff S2 and S3 assisted as well once they heard the commotion. R2 confirmed that either S1 or S3 were present in the area and staff members pulled R1 off of him/her. The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the Department has found that the allegation of neglect/lack of supervision were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. No deficiencies cited during today’s visit. A copy of the report was provided to ADM.

A Noncompliance meeting was conducted on February 8, 2024 at CCLD San Jose office. Present at the meeting were San Bruno Adult and Senior Care Regional Manager Vivien Helbling, Licensing Program Manager Romeo Manzano, Licensing Program Analysts Simi Rai and Manuel Monter, Licensee/Administrator Samuel C Apostol. The purpose of the noncompliance meeting was to discussed a substantiated complaint allegations for the following date: 08/25/2022, 2/10/2022, 03/15/2018. As a result, the allegation is Substantiated. Deficiencies were cited for violations of Title 22 California Code of Regulations. Noncompliance Conference Summary LIC 9111 and compliance plans were established during the meeting. The facility will begin a 2 year monitoring plan by licensing which includes more frequent licensing inspections. Additional civil penalties are being reviewed. Report was reviewed with facility Licensee. A copy of this report, LIC 9111 was provided to licensee during today's office visit.

LPA's interviewed 10 residents. 8 out of 10 residents denied the allegation that staff were teasing, taunting or saying mean things to residents. 7 out of 10 residents denied the allegation that residents were taunting, teasing, or saying mean things to other residents. LPA's interviewed 3 staff members, S1-S3. 3 out of 3 staff members denied the allegation that staff were teasing, taunting or saying mean things to residents. 3 out of 3 staff members denied the allegation that residents were taunting, teasing or saying mean things to other residents. LPA's interviewed ADM regarding the allegations. ADM stated the staff do not tease/taunt/say mean things to residents. ADM stated the residents will sometimes tease/taunt/ say mean things to one another. ADM stated the facility staff will intervene and de-escalate the situation. ADM stated the staff will try to re-direct the residents and encourage to cooperate as they live in the same home. ADM stated R1 accuses ADM of speaking with his/her wife. ADM stated R1 accuses others of talking with his/her wife. A review of R1's Appraisal/Needs and Services Plan states; R1 struggles from paranoid thoughts and behaviors(past characterized by a generalized over concern of others). The form states R1 has delusional thoughts such as thinking his/her "girlfriend" is imprisoned. The form also states R1 is fixated on his/her "fiance" and paranoid of people talking to her or saying bad things. The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. No deficiencies cited, an exit interview conducted with Administrator, Sam Apostol and a copy of the report was provided.

Licensing Program Analysts (LPA) Manuel Monter and Mita Partoza conducted an unannounced annual inspection visit, and met with Administrator(ADM) Sam Apostol. LPA toured the facility inside out with ADM which included; the Living room, kitchen, dinning room, facility restrooms and 10 residents bedrooms. During LPA's tour of the resident bedrooms, LPA's observed residents bed sheet were observed to be recently changed. The medication room of the facility was also inspected. Front yard and backyard were inspected. LPA observed fly traps were observed and ADM stated the facility changes the fly traps once a week. There was no obstruction to block the walkways. LPA observed the front yard free of debris and in good condition. Two day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 75 degree F, and hot water temperature was measured in 3 facility bathrooms. The water temperature ranges from 105 to 110 degrees F. Fire extinguisher was serviced in March 2023. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. The fire alarm system was last inspected on 07/06/2023. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on October 2023. LPA reviewed facility records for 3 staff and 4 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 4 staff (S1 to S4) and 4 residents (R1-R4). No deficiencies cited during today's visit. This report was reviewed with ADM Sam Apostol and a copy of the signed report was provided.

LPA Manuel Monter conducted an unannounced case management visit in regards to an incident report the department received on 7/28/2023. LPA met with administrator (ADM) Samuel Apostol. On 7/28/23 the department received an incident report regarding resident R1 assaulting resident R2 around 12pm. R2 was taken to the hospital and has returned to the facility. R1 was arrested by the sheriff. ADM stated he will not accept resident R1 back to the facility. ADM was interviewed regarding his plan of action on keeping his residents safe and the facility's procedures for when residents begin to argue/fight with each other. ADM stated that the facility was actively watching resident R1 due to he/she no longer taking his/her medication. ADM stated on 7/24/23, resident R1 was beginning to refuse medication and claiming to staff that he/she fired the facility's staff as he/she is the owner. ADM stated he contacted the case manger, conservator and psychiatrist regarding resident R1 refusing to take his/her medication. ADM stated he informed his staff to keep an eye on R1 who was not taking his her medication. ADM stated R1 and R2 are not roommates. ADM stated the facility will encourage resident who do not get along to avoid interacting with each other to avoid conflicts. LPA asked for the following documents. The facility staff schedule, R1's progress notes, police report case number card. LPA also requested R1 and R2's updated appraisal needs and services plan. LPA advised ADM to put his plan of action on future incident reports. LPA toured the facility. No deficiencies cited during todays visit. A copy of the report was provided to ADM

LPAs Rai and Monter and LPM Manzano conducted an unannounced case management visit-plan of correction (POC) visit. Met with Administrator Sam Apostol. The purpose of this visit is to ensure that the facility administrator and staff are adhering to the Plan of Corrections submitted to the department as a result of citations and deficiencies issued on the following inspection/investigation visits: LPAs and LPM also met with 3 Rehab Counselors from Santa Clara County Behavioral Health (SCCBH). SCCBH has 36 residents at this facility. SCCBH counselors, LPAs/LPM and Administrator had a meeting wherein the importance of 'collaboration and accountability'' between the facility and SCCBH is vital to ensure that needs and supervision of residents in the facility are discussed and individual assessment or plan of care is in place. SCCBH agreed to initiate 'care conference' quarterly and as needed to note significant changes in physical, medical, mental and social condition of each resident. Administrator will reach out to case manager/social worker of residents which are not under SCCBH. SCCBH joined LPAs/LPM during tour of the facility and random checks of residents' bedrooms. Administrator agreed and understood that collaboration with SCCBH and other agencies is important. Based on today's inspection visit, the Administrator and staff have corrected all of the above citation/deficiencies. POC clearance are issued and provided to Mr. Apostol. No deficiencies cited during today's visit.

Facility administrator falsifies training records The allegation stated th e facility administrator falsifies the staff training records and puts the fake records in the staff files. During record review of staff files and training logs, LPA observed the training logs from 2013-2023. LPA observed either an RN, Administrator Sam Apostle or a third party vendor was providing facility staff training. The training logs which captured the staff signatures were made with different color ink and different signatures. Staff did not notify resident's authorized representative of residents fall The allegation stated the Resident (R1) had a fall on 8/13/22 and the staff also did not notify the resident's authorized representative that the resident fell. A staff member called the resident's authorized representative on or around 8/15 or 8/16/22 to let the authorized representative the resident was being sent to the hospital. During today's visit 6/22/2023, LPAs interviewed ADM and ADM stated the family was notified about the fall via phone call and does not have written record of the call. The Department has investigated the above allegations. Based on LPA inspection, observations, records review, interviews with AD, staff, and residents, the preponderance of evidence standard has not been met therefore the allegations are UNSUBSTANTIATED. Meaning although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Administrator Samuel Apostol and a copy of the report was provided. 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 administer medication without medication training The allegations stated a staff member (S1) without training is providing medications to the residents. Per interview with Administrator (ADM) Sam Apostol, facility staff did not have training due to the pandemic. LPAs reviewed the medication logs from September and October 2022 which includes the resident's medications, date and time the staff initials stating when and who gave the medications to the resident. ADM reviewed the initials on the medication record and they did not belong to S1. Per staff interviews and resident interviews, S1 gives residents medications in the morning. LPAs interviewed S1, S1 stated S1 has given medications in the past couple of years when Med-Tech is on vacation or calls off sick. S1 stated did not receive medication training. Per S1, the medication is in little brown envelopes which are prepared in advance. Per record review, S1 has not received medication training in prior years, the only training record for S1 is for the year 2023. Staff did not report incident involving resident to CCLD The allegation stated the resident's fall which occurred on 8/13/2022 was not reported to CCLD by submitted an incident report. During today's visit, 6/22/2023, LPAs interviewed ADM and ADM could not produce the incident report for the resident's fall. ADM did report the hospitalization of the resident which occurred a couple of days later. The Department has conducted an investigation of the above allegations. Based on interviews and records review, the preponderance of evidence standard has been met. Therefore, the Department found the above allegations to be SUBSTANTIATED. Deficiencies are being cited. See LIC 9099-D. Exit interview conducted with Administrator, Sam Apostol . A copy of this report, along with the facility's appeal rights were provided.

During interview with ADM. ADM stated R1 did not come forward with the allegation. The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. No deficiencies cited, Exit interview conducted with Administrator, Sam Apostol and a copy of the report was provided. Page 2 out of 2

The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. No deficiencies cited, Exit interview conducted with Administrator, Sam Apostol and a copy of the report was provided. Page 2 out of 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 Based on the interviews conducted with clients and staff, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED. No deficiencies cited, Exit interview conducted with ADM, Sam Apostol and a copy of the report was provided. Page 2 out of 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 Based on interviews and observation/inspection of the facility, the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED. Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 9099-D. This report was reviewed with Administrator Sam Apostol and a copy of the report was provided. Appeal Rights was provided. Page 2 of 2

ADM stated EPS was informed that R1 has to be stable prior to returning back to the facility. ADM stated that R1's social worker and 24 hour care were aware, involved and agreed that R1 need a higher level of care and subsequently admitted to a secured facility in San Jose. Staff (S1) stated that R1 was not picked up by EPS rather they called the Sheriff. Sheriff took R1 to Momentum Crisis Residential. ADM stated that the facility is willing to work with their residents and with their responsible party but when a resident has an uncontrolled behavior and being disruptive in the facility, they ADM denied allegation that R1 was illegally evicted. The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. No deficiencies cited, Exit interview conducted with Administrator, Sam Apostol and a copy of the report was provided.

Resident was not fed ADM stated that R1's diet was good. ADM stated that his/her staff does not deprived R1 from not eating for 3 days rather the opposite, R1 was throwing his/her food on the floor and milk towards staff when exhibiting behaviors. ADM stated that R1's appetite was very good. Staff (S1) stated that R1 was being given meals and snacks but when exhibiting behavior the resident threw his/her food instead of consuming it. Medication was not given to resident at proper time. Based on allegation, the facility staff did not administer R1's medication timely manner causing his/her to have a stomach pain due to an empty stomach. ADM and staff stated that R1's medications were administered to R1 in a timely manner, nor they have any knowledge of the incident. Resident was assaulted by another resident Based in allegation, the resident was assaulted by another resident at the facility. Staff (S1) stated R1's roommate would complain because R1 would leave the window open and R1's roommate would be cold. The facility documented this incident occurring 2/5/2023 and 2/9/2023. During interview, S1 stated they had verbal agreements but both residents were not physical toward each other or other residents. Staff not intervene in resident on resident altercation ADM stated that R1 and R2 had an altercation wherein it was not witnessed. ADM stated that when R1 was in the facility, R1 had a behavior wherein he/she was not listening when being redirected. ADM stated that R1 threw milk at staff and scattered his/her clothes (clean and dirty) in his/her room and in the facility. Page 2 of 3. Continuation on page 3, 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 Page 3 of 3. Based on the interviews conducted with clients and staff and based on observation and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED. No deficiencies cited, Exit interview conducted with Administrator, Sam Apostol.

Resident was left soiled During previous inspection 5/19/2023, an interview with staff and ADM stated that bedsheets are changed every once a week except when a resident has an accident such incontinence. LPA inspected R1's bedroom #19, R1's linen had dry urine stain & R2's pillow had dry blood due to severe acne. R1 is incontinent. During today's visit, staff stated they were in the middle of assisting residents and changing everyone's linens during our inspection. LPAs and LPMs did not observe staff who were soiled. Resident's hygiene needs are not being met According to the allegation, the residents were seen strangely filthy at the facility. During today's tour of the facility , residents were observed during meal time, and around the property. There were no complaints regarding the staff not attending to their needs. The residents were observed not to be disheveled . LPAs and LPM observed the residents to be wearing clothes without stains and unintentional rips. During interview with residents, all 4 residents were independent with their grooming and asked staff for help if they need it. During inspection, there was an odor in Room #12. The resident (R1) does not get up and resident is incontinent with bladder. According to the ADM, they were cleaning the resident and the room and they will follow up with social worker. The resident refuses to wear incontinent pad and a plastic cover has been placed over the mattress. Resident's bed was not properly maintained LPAs randomly inspected residents bedrooms. Residents' were also interviewed. Residents provided responses that bedsheets are washed during different times of the week. During today's inspection, 6/7/2023, the resident rooms were made with blankets tucked in and was clean of dirt and debris. Resident was unable to shower while in care During today's inspection, 3 Out of 4 residents interviewed stated they take a shower themselves and 1 out of the 4 residents interviewed stated they need help while taking a shower. All 4 residents interviewed stated the staff administer the medication during scheduled time. During inspection, LPAs and LPM observed the shower room to be unlocked and a schedule of the resident showers was posted outside. Page 2 out of 3, see continuation on LIC 9099-C (Page 3). 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Page 3 out of 3. Residents medication is not given appropriately ADM and staff stated that R1's medications were administered to R1 in a timely manner, nor they have any knowledge of the incidents where medication was not given. The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. No deficiencies cited, Exit interview conducted with Administrator, Sam Apostol and a copy of the report was provided.

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Samuel Apostol. During visit, LPA Marrufo toured the facility. LPA Marrufo observed a 30-day supply of PPEs, perishable food supply of at least 2 days and a non-perishable food supply of at least 7 days. LPA Marrufo observed the facility bathroom had available soap, paper towels, and hand washing signs. The outdoor area exits were clear of obstructions. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Samuel Apostol and a copy of the report was provided.

Licensing Program Analyst (LPA) Marybeth Donovan arrived unannounced to conduct a Case Management- Health Checks Visit. LPA met with Samuel Apostol Administrator and Yvonne Chavez Med Tech. LPA toured the facility to include the Medication Room. LPA interviewed Administrator and 4 staff and reviewed training records. Medications are stored in a medication cart located in locked medication room. Overflow medication is stored in locked Medication Closet in the locked facility office. LPA discussed Centrally Stored Medication Storage and Medication Training and provided a copy of Medication Training Requirements. See attached LIC9102 Advisory Note regarding Centrally Stored Medication Storage. LPA reviewed report with Samuel Apostol Administrator and a copy provided.

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Samuel Apostol. During visit, LPA Marrufo toured the facility inside and out. LPA Marrufo observed a visitor screening area at the entrance. LPA Marrufo toured the facility kitchen, pantries, and refrigerators and observed a perishable food supply of at least 3 days and a non-perishable food supply of at least 7 days. LPA Marrufo observed a PPE supply of at least 30 days. LPA Marrufo observed COVID-19 related posters throughout the facility hallways. The facility bathrooms has available soap and paper towels and hand washing signs. LPA Marrufo toured the outside area and observed the exits to be clear of obstructions. No deficiencies were cited as per California Code of Regulations Title 22. This report was reviewed with Samuel Apostol and a copy of the report was provided.