Cogir of San Rafael.

At approximately 8:55AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Other visit and met with Executive Director, Kimberly Humphrey. The purpose of today's visit was to conduct the facility's quarterly Non-Compliance inspection and to follow up on self reported incident reports that were submitted to the Santa Rosa Regional Office (SRRO). LPA reviewed files for staff members hired from February 2026 to April 2026 related to the below concerns: Reporting Requirements Personal Rights Incidental, Medical, and Dental Care Welfare and Institutions Code Administrator and Designated Representatives LPA observed that identified staff members hired within this time frame had appropriate training documented or their training was scheduled to be completed. LPA requested for copies of scheduled training to be submitted to the Department once complete. Community Care Licensing (CCL) received the following incident reports: Incident Report 1 was submitted to CCL on 02/04/2026. Report states that on 01/31/2026, Resident 1 (R1) was observed sitting in a car in the facility's parking lot. The car belonged to another resident's family member. R1 was redirected back to the facility. Facility made all appropriate notifications per regulation. Review of R1's care plan dated 12/31/2025 stated that R1 did not have a history of elopement. Per Executive Director, this Continued on LIC809C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Continued from LIC809 incident prompted facility to have R1 reassessed for this change of behavior. Review of R1's updated Physician Report dated 02/16/2026 and updated Care Plan dated 02/12/2026 showed they are unable to leave unassisted. Incident Report 2 was submitted to CCL on 03/26/2026. Report states that on 03/25/2026, R1 was observed pulling the hair of Resident 2 (R2). Facility staff intervened, separated the residents, and assessed for injury. Facility made all appropriate notifications per regulation. Incident Report 3 was submitted to CCL on 03/26/2026. Report states that on 03/25/2026, R1 was observed to hit Resident 3 (R3) twice on the cheek with a closed hand. Facility staff intervened, separated the residents and assessed for injury. Facility staff provided first aid. Facility made all appropriate notifications per regulation. Incident Report 4 was submitted to CCL on 04/02/2026. Report states that on 04/02/2026, R4 fell and hit their head on the floor in their room. Per report, the incident occurred due to Staff Member 1 (S1) not ensuring that R4 was sitting properly in their wheelchair before being transferred, causing R4 to fall forward onto the floor. Paramedics were contacted to further evaluate R4 and responsible party refused transport to the Emergency Room. R4 was placed on 72 hour observation. Facility made all appropriate notifications per regulation. Incident Report 5 was submitted to CCL on 04/20/2026. Report states that on 04/15/2026, Resident 5 (R5) was observed to grab Resident 6 (R6) by the back of their head and hit the top of their head with an open palm. Facility staff intervened, separated the residents, and assessed for injury. Facility made all appropriate notifications per regulation. LPA obtained copies of documents related to the incidents. Elopement training was conducted on 02/04/2026 and 02/18/2026. Deficiency cited under Regulation 87705(e)(7) is being cleared today during visit. Plan of Corrections Letter provided. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, Plan of Corrections, Appeal Rights, Plan of Corrections Letter, and LIC811 (Confidential Names) discussed and provided to Executive Director. Signature on form confirms receipt of documents.

Continued from LIC9099A Review of facility schedule for 08/23/2025 showed that there were 8 direct care staff on-site during the evening shift. Review of staff records indicated that 8 of 8 facility staff members had first aid training certificates on file. This allegation is Unsubstantiated . The Department investigated the following allegation, “staff do not ensure that facility is in good repair.” Complaint alleged that facility’s camera system was not working. Complaint alleged that facility staff were aware that the system was down on the morning of 08/23/2025 but did not communicate it to residents or their responsible parties. Facility partners with a third-party vendor, Safely You, that has cameras throughout the building to notify the facility staff of a potential fall. Interview conducted with Executive Director stated that Safely You Technicians were on-site for 3 to 4 days to resolve the camera issue. Facility documents also indicated that on 08/29/2025, the Safely You cameras were online and active. The camera system is maintained and managed by Safely You. Therefore, it is the third-party vendor’s responsibility to ensure that their system is functioning appropriately and not the facility’s. This allegation is Unsubstantiated . A finding that a complaint allegation is Unsubstantiated means 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. Exit interview conducted. Copy of report discussed and provided to Executive Director/Administrator. Signature on form confirms receipt of documents. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Continued from LIC9099 Review of R1’s call pendant records for August 2025 indicated that on 08/24/2025, R1’s pendant was pulled at 8:11AM and was not received or responded to as of 8:56AM. Review of R1’s call pendant records for September 2025 indicated that on 09/24/2025, R1’s pendant was pulled at 9:45AM and was not received or responded to as of 10:30AM. Additional review of R1's pendant call records also showed that on 09/25/2025, R1’s pendant was pulled at 6:06PM and was not received or responded to as of 6:51PM. Per interview with Health and Wellness Director, it was identified that some facility staff were not wearing or using their pagers as required. Health and Wellness Director also stated that they identified that the facility also had a low supply of employee pagers. Review of facility documents showed that an Standard Operating Procedure (SOP) document titled, "Use of Pagers for Responding to Pull Cord Alerts," was signed by facility staff on 08/30/2025. Based on record review, interviews, and observations made, this allegation is Substantiated . A finding that the Complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, Plan of Corrections, and Appeal Rights, discussed and provided to Executive Director. Signature on form confirms receipt of documents.

At approximately 8:50AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year Visit and met with Business Office Director, Ditter Vazquez and Resident Care Coordinator, Mariana Ramirez . Executive Director, Kimberly Humphrey, arrived during visit at approximately 9:50AM. Facility serves residents with dementia and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and capacity for 70 non-ambulatory residents, of which 20 residents can be bedridden. Facility has an approved hospice waiver for 16 individuals. Facility is currently on a Non-Compliance Plan. Upon arrival, LPA was informed that there were 55 residents in care and 20 staff members on-site. At approximately 9:25AM, LPA reviewed Facility Staff Roster and found that all staff members on site were background cleared and associated to the facility per regulation. LPA conducted a walk-though of the facility with Executive Director and observed the following: Facility is a 2 story building. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility has a infection control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins were observed to be stored inaccessible to residents. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Mattress pads were in place or available for Resident use. Facility fire extinguishers were last inspected March 2025. During walk-through, LPA observed the following deficiencies: 4 of 8 resident sinks were found to be out of compliance with Title 22 regulations of 105 to 120 degrees Fahrenheit, measuring at 120.7F, 120.2F, 121.4F, and 122.1F (deficiency cited, regulation 87303(e)(2)), 5 instances of unlabelled and undated foods were observed (deficiency cited, regulation 87555(a)), and facility did not have adequate emergency water supply in the event facility had to shelter in place for at least 72 hours (deficiency cited, Health and Safety Code, 1569.695(a)(2)). Continued on LIC809C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Continued from LIC809 LPA reviewed a sample size of 4 staff files. Files were all found to be well organized, thorough and contained the required documentation. Staff files had current First Aid and/or CPR certification and required annual training. Administrator Certificate for Kimberly Humphrey (7009689740) was current with an expiration date of 09/01/2026. LPA unable to complete Annual Inspection. Annual Continuation Visit to be conducted at a later date. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC809D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Executive Director/Administrator. Signature on form confirms receipt of documents.

At approximately 11:55AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Other visit and met with Executive Director, Kimberly Humphrey. The purpose of today's visit was to conduct the facility's quarterly Non-Compliance inspection and to follow up on an incident report that was self submitted to Community Care Licensing (CCL). LPA reviewed files for staff members hired between July 2025-October 2025 related to the below concerns: Reporting Requirements Personal Rights Incidental, Medical, and Dental Care Welfare and Institutions Code Administrator and Designated Representatives LPA observed that identified staff members hired within this time frame had appropriate training documented. LPA followed up on an incident report that was submitted to CCL on 10/01/2025. Report states that on 09/25/2025, Resident 1's (R1's) medication was administered to Resident 2 (R2). Per report, both residents have the same medication with the same dosage. Residents were placed on 72 hour monitoring to observe for any adverse effects (deficiency cited, LIC809D, regulation 87465(a)(4)). Facility provided proof of training conducted on 09/25/2025 on "The Six Rights" related to the incident report. Deficiency cleared during visit and Corrections Letter provided. Continued on LIC809C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Continued from LIC809 **An immediate civil penalty assessment in the total amount of $250.00 has been issued for a repeat violation of Regulation 87465(a)(4) more than once in a 12 month period. Regulation last cited on 01/23/2025.** (See LIC421FC) Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC809D, LIC421FC, Plan of Corrections, Appeal Rights, and Corrections Letter discussed and provided to Executive Director. Signature on form confirms receipt of documents.

At approximately 9:30AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Incident Visit and met with Executive Director, Kimberly Humphrey, and Health and Wellness Director, Florence Van Heusden . The purpose of the visit was to follow up on incident reports that were submitted to Community Care Licensing (CCL). Incident Report 1: CCL received an incident report on 07/23/2025. Report stated that on 07/18/2025, facility staff witnessed Resident 1 (R1) exit the facility through the main door. Facility staff immediately followed R1 to redirect back to the facility but R1 refused. Facility staff followed R1 on foot and by car to the freeway. Facility contacted San Rafael Police Department and R1 was taken to the hospital for further evaluation. Facility made all notifications per regulation. I ncident Report 2 : CCL received an incident report 07/30/2025. Report stated that on 07/26/2025, Resident 2 (R2) exited the facility through the main door and crossed the street. Staff Member 1 (S1) was outside with another resident's dog and observed R1 outside. S1 notified additional staff members for assistance and R1 was redirected back to the facility. Facility made all notifications per regulation. LPA obtained additional documentation related to the incidents and copies of elopement training conducted on 07/31/2025 and 08/04/2025. *Deficiency issued today under Regulation 87705(d) has been cleared with Plan of Corrections letter provided during visit. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) d ue date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, Plan of Corrections, Appeal Rights, and Plan of Corrections Letter discussed and provided to Executive Director. Signature on form confirms receipt of documents.

Continued from LIC9099 "Staff handled resident roughly causing resident to fall" - Community Care Licensing received an Incident Report and SOC341 Report on 02/25/2025. Reports stated that 02/21/2025, facility received a notice from their fall-detection camera system. Reports stated that in the video footage, Staff Member 1 (S1) was seen grabbing R1, was trying to clean them after they used the bathroom, and that R1 was resistant to receiving the care. Reports further stated that R1 was seen falling backward hitting their head against their bedroom furniture, that S1 did not report the fall to Facility Medication Technicians or the Health and Wellness Director (HWD) on duty, and that Staff Member 2 and Staff Member 3 (S2 and S3) conducted a visual assessment of R1. LPA reviewed the facility video footage from 02/21/2025. LPA observed that R1 was shown to fall backward with force and significantly hit their head on their nightstand while S1 was providing care. "Facility did not seek timely medical" - Review of R1’s physician orders indicated that R1 was on a blood thinner medication/anticoagulant. Interviews conducted with S2 and S3 confirmed that they reviewed the video footage on 02/21/2025 and conducted a visual assessment of R1. Interviews revealed that S2 and S3 did not send R1 to the hospital for evaluation per facility protocol because they were instructed by the HWD to not send R1 to the hospital unless they exhibited a change in condition. Per interview with Executive Director, facility protocol is to call emergency services when a resident hits their head. Review of facility’s fall policy stated the following: “…Associates will call Emergency Medical Services (911) when: (a) the resident has…received obvious head or significant trauma, (b) if the resident is on anticoagulants and there is a question of head trauma.” "Facility did not report abuse to responsible party" - Review of SOC-341 report showed that R1's incident occurred on 02/21/2025 and that the report was received by Community Care Licensing (CCL) on 02/25/2025. Welfare and Institutions Code section 15630(b)(1) states the following: "Any mandated reporter who, in his or her professional capacity, or within the scope of his or her employment, has observed or has knowledge of an incident that reasonably appears to be physical abuse...shall report the known or suspected instance of abuse...within two working days." Interviews conducted with S2 and S3 confirmed that they viewed the video of R1 and S1 on 02/21/2025 and did not report the suspected abuse incident timely per mandated reporting requirements. Continued on LIC9099C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Continued from LIC9099C Based on record review, interviews conducted, and observations made, these allegations are Substantiated. A finding that the Complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC9099D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Business Office Director. Signature on form confirms receipt of documents.

Continued from LIC9099 residents' calls were still showing up on the facility's monitors if a resident's pull cord or resident pendant was used. Executive Director stated that issue was that the system was not allowing new pendants to be programmed and therefore current residents that required a replacement pendant were unable to receive one. Facility contacted their Call System company, Lifeline Senior Living, to have a systems technician conduct a repair. Per Executive Director, as of Monday, 03/10/2025, the facility's call system has been updated, all pull cords and resident pendants have been checked to ensure they are fully functioning/operable. Executive Director stated that when the system was malfunctioning, care staff were doing increased checks on residents. LPA conducted staff interviews. 4 of 5 interviews conducted stated that resident pull cords have not been working as expected and that sometimes they do not receive the calls on their pagers. Interviews conducted revealed that they have been told it's a problem with the system and that management has been working on getting it resolved. Review of facility documents showed that Lifeline Senior Living provided a quote of repairs to the facility on 03/04/2025. Based on interviews conducted and document review, this allegation is Substantiated . A finding that the Complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC9099D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Executive Director. Signature on form confirms receipt of documents.

At approximately 9:00AM, Licensing Program Analysts (LPAs) Felias and Magdaleno arrived unannounced to continue a Required 1 Year Visit and met with Business Office Director, Ditter Vasquez, and Wellness Nurse, Remy Fairbairn. Executive Director, Kimberly Humphrey, arrived during visit at approximately 12:30PM . Facility serves residents with dementia and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and capacity for 70 non-ambulatory and bedridden residents. Of the 70 residents, 20 residents can be bedridden. Facility has an approved hospice waiver for 16 individuals. Facility is currently on a Non-Compliance Plan. Upon arrival, LPAs were informed that there were 47 residents in care and 19 staff members on-site. LPAs reviewed Facility Staff Roster and found that all staff members on site were background cleared and associated to the facility per regulation. LPAs reviewed staff and resident files and resident medication. During staff file review, LPAs observed that 5 of 6 staff members did not have current First Aid certification, and 3 of 6 staff members did not have CPR certification (deficiency cited, LIC809D, Health and Safety Code 11569.618(c)(3)). During resident file review, LPAs observed that 1 of 5 residents did not have an updated Physician's Report as required (technical violation issued, LIC9102, regulation 87463(h)). Medication was found to be centrally stored and secure. As part of their Non-Compliance Plan, LPAs also requested and reviewed documents for all employees hired from November 2024 to January 2025. Review of documents showed that facility hired 5 individuals during this time frame. Document review showed that facility has conducted training or have scheduled training for them in the following areas: Reporting Requirements Personal Rights Incidental, Medical, and Dental Care Welfare and Institutions Code Administrator and Designated Representatives LPAs followed up on incident reports that were submitted to Community Care Licensing (CCL): Continued on LIC809C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Continued from LIC809 Incident Report 1/SOC341 : CCL received an incident report and SOC341 on 12/02/2024. Reports state that on 11/25/2024, Staff Member 1 (S1) observed Staff Member 2 (S2) taking Resident 1's (R1) medication card from the facility medication cart. Per reports, S2 also took two Tylenol tablets from R1's medication bottle. Facility conducted an internal investigation and medication audit and found that 42 tablets were missing from R1's medication. Reports stated that facility conducted an in-service training. Facility made all appropriate notifications per regulation. Executive Director informed LPAs that S2 has since been terminated and is no longer working at facility. LPAs obtained copy of in-service training. Incident Report 2 : CCL received an incident report on 01/23/2025. Report states that on 01/15/2025, Staff Member 3 (S3) observed that Staff Member 4 (S4) did not give Resident 2 (R2) their medication as prescribed on 01/14/2025. Additional documentation showed that R2's medication was documented as given. S2 notified management and a medication audit was conducted (deficiency cited, LIC809D, regulation 87465(a)(4)). Report stated that S4 was suspended pending internal investigation and that facility would receive in-service training. Facility made all appropriate notifications per regulation. Executive Director informed LPAs that S4 has seen been terminated and is no longer working at facility. LPAs reviewed Facility's Guardian Roster and confirmed that S2 and S4 have been removed from the facility and are no longer working on-site. LPAs requested the following documents to update facility file: Designation of Facility Responsibility (LIC 308) Emergency Disaster Plan (LIC 610D) Updated Personnel Report (LIC 500) Updated Liability Insurance Active and Current Administrator Certificate Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC809D, LIC811 (Confidential Names), Plan of Corrections, and Appeal Rights discussed and provided to Executive Director. Signature on form confirms receipt of documents.

Continued from LIC9099 Per HWD, TSPs are temporary services provided by the facility that goes on a resident’s care plan. A resident’s level of care is determined by a point system which is generated into an invoice. Review of facility documents showed that R1 received wound care orders on 02/06/2024 which were not discontinued until 02/27/2024. Facility documents indicated that R1’s Responsible Party received verbal notification on 02/06/2024 that R1’s care level would be affected due to requiring wound care services. On 02/21/2024, R1’s Responsible Party was verbally notified that the wound care services would stay in place since the orders were not discontinued by the Physician. Facility was unable to provide documentation showing that R1’s Responsible Party had received a written notice of R1’s updated service plan with the additional charges included. Therefore, this allegation is Substantiated . There is an allegation that “Facility did not respond to Representative timely.” Complainant stated that R1’s Responsible Party contacted the facility multiple times to address charges related to R1’s care. Email correspondence provided to LPA indicated that R1’s Responsible Party contacted the facility on 04/04/2024. Responsible party was told that they would have an answer to their inquiry by 04/08/2024. Further correspondence indicated that R1’s Responsible Party followed up on 04/17/2024 and still did not receive a response. Therefore, this allegation is Substantiated . A finding that the Complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC811 (Confidential Names), LIC9099D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Regional Executive Director. Signature on form confirms receipt of documents.

At approximately 9:10AM, Licensing Program Analysts (LPAs) Florio and Felias arrived unannounced to conduct a Case Management - Legal/Non-compliance visit and met with Administrator/Executive Director, Susan Edwards. Facility serves residents with dementia and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and capacity for 70 non-ambulatory and bedridden residents. Of the 70 residents, 20 residents can be bedridden. Facility has an approved hospice waiver for 16 individuals. LPAs requested and reviewed documents for all employees hired from January 2024 to April 2024. Review of documents showed that facility hired 2 individuals during this time frame and has either conducted training or have scheduled training for them in the following areas: Reporting Requirements Personal Rights Incidental, Medical, and Dental Care Welfare and Institutions Code Administrator and Designated Representatives. LPAs conducted a walkthrough with Executive Director. During walkthrough, LPAs observed that a medication cart was unattended and unlocked. LPAs observed that routine and narcotic medications were on top of the unlocked cart. LPAs notified the medication technician on duty who immediately put the medications away and locked the cart (this deficiency has been cited, see LIC809-D, Regulation 87705(f)(2)). Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. **An Immediate Civil Penalty in the total amount of $1,000 is being assessed for a repeat violation of Regulation 87705(f)(2) for a third or subsequent cited violation within 12 months of the last violation . (See LIC421IM)** Exit interview conducted. Copy of report, LIC809D, LIC421IM, Plan of Corrections, and Appeal Rights discussed and provided to Executive Director. Signature on form confirms receipt of documents.

At approximately 9:50AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Annual Continuation visit and met with Executive Director/Administrator, Susan Edwards. Upon arrival, LPA was informed that there were 49 Residents in care and 26 staff members on-site. At approximately 10:00AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. LPA reviewed 6 resident files and 4 resident medication records. Resident files were all found to be well organized, thorough and contained the required documentation. Medication was found to be centrally stored and secure. LPA also followed up on an incident report that was submitted to Community Care Licensing (CCL). Incident Report 1: CCL received a incident report on 02/12/2024. Report stated that on 02/09/2024, Resident 1 (R1) was found by facility staff at the end of the facility's driveway. Report stated that the facility's front door has delay egress and was alarmed. Facility made all appropriate notifications per regulation. (This deficiency has been cited, see LIC809D, Regulation 87705(b)(2). LPA requested the following documents to update facility file: Designation of Facility Responsibility (LIC 308) Emergency Disaster Plan (LIC 610D) Updated Personnel Report (LIC 500) Register of Clients/Residents (LIC 9020) Updated Liability Insurance Active and Current Administrator Certificate Facility Documents to be submitted to Community Care Licensing (CCL) by due date of 03/14/2024. Continued on LIC809C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Continued from LIC809 Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC809D, Plan of Corrections, and Appeal Rights discussed and provided to Executive Director. Signature on form confirms receipt of documents.

At approximately 11:00AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year Visit and met with Administrator/Executive Director, Susan Edwards. Facility serves residents with dementia and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and capacity for 70 non-ambulatory and bedridden residents. Of the 70 residents, 20 residents can be bedridden. Facility has an approved hospice waiver for 16 individuals. Facility is currently on a Non-Compliance Plan. Upon arrival, LPA was informed that there were 49 residents in care and 9 direct care staff on-site. At approximately 11:30AM, LPA reviewed Facility Staff Roster with Executive Director and found that all staff members on site were background cleared and associated to the facility per regulation. At approximately 12:00PM, LPA conducted a walk-though of the facility with Executive Director and observed the following: Facility is a 2 story building. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility has a infection control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins were observed to be stored inaccessible to residents. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Mattress pads were in place or available for Resident use. Hot water temperatures for a sample size of 10 sinks were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. Facility's fire extinguishers were last inspected April 2023. Facility's smoke and carbon monoxide detectors and sprinkler system were last inspected December 2023. Facility's last fire/disaster drill was conducted January 2024. LPA reviewed staff files. Files were all found to be well organized, thorough and contained the required documentation. Staff files had current First Aid and CPR certification. Continued on LIC809C 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 **Report has been Amended** Continued from LIC809 As part of their Non-Compliance Plan, LPA also requested and reviewed documents for all employees hired from November 2023 to January 2024. Review of documents showed that facility hired one individual during this time frame. Document review showed that facility has conducted training or have scheduled training for them in the following areas: Reporting Requirements Personal Rights Incidental, Medical, and Dental Care Welfare and Institutions Code Administrator and Designated Representatives LPA also followed up on an incident report/SOC-341 that was submitted to Community Care Licensing (CCL). Incident Report 1/SOC341: CCL received an incident report/SOC-341 report on 01/08/2024 and 01/10/2024. Reports stated that on 01/07/2024, during a routine check, facility staff found Resident 1 (R1) and Resident 2 (R2) in bed together in R1's room. Facility self-reported incident, facility contacted responsible parties for both residents. Facility has implemented the following; · 1:1 supervision for R2, · 30 minute checks after 8PM · Continuous alert charting for R1 and R2 · Service care plans have been updated for both residents Facility understands that residents are able and allowed to have a relationship with each other. Facility understands that if residents were prevented having a relationship or are prohibited from seeing each other, it may be a personal rights violation. Based on review of incident report and SOC-341, Facility has been compliant with Title 22 Regulations regarding Personal Rights. Incident Report 2: Executive Director also informed LPA that yesterday evening, 01/28/2024, facility staff found a box of wine in Resident 3's (R3) room. The wine was immediately removed from R3's room. LPA informed that R3 has a Physician's Order to have alcohol, and an LIC624/Unusual Incident Report submitted to the Regional Office. Continued on LIC809C 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 **Report has been Amended** Continued from LIC809C Facility sent out a notice to all Responsible Parties outlining items that are not allowed to be in the building and plans on conducting an in-service training for staff reviewing prohibited items such as alcohol. (This regulation has been cited, see LIC809D, Regulation 87705(f)(2)).” Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. **An Immediate Civil Penalty in the total amount of $250 is being assessed for a repeat violation of Regulation 87705(f)(2) more than once in a 12 month period. (See LIC421IM)** Exit interview conducted. Copy of report, LIC811 (Confidential Names), LIC809D, LIC421IM, Plan of Corrections, and Appeal Rights discussed and provided to Executive Director. Signature on form confirms receipt of documents. Physical Copy of signatures on file.

Continued from LIC9099A On 04/29/2023, R1 communicated to Staff that they did not feel well and had leg pain. Review of Facility documentation and incident reports indicated that R1’ s Responsible Party was contacted and informed of R1’s condition on 04/29/2023. Report reviewed stated R1’s Responsible Party declined having 911 called for R1, and that they did not want emergency transport provided. This allegation is Unsubstantiated. There is an allegation that Staff did not observe change in resident’s condition. The Report states the following concerns: Staff did not observe R1’s wheezing and coughing, Staff did not observe R1’s stomach distention, and Staff did not observe a change in R1’s legs. Review of R1’s Progress notes showed that on 04/24/2023, Staff observed R1 to have a moist cough. Staff contacted R1’s Primary Care Physician on 04/25/2023 when it was observed that R1’s cough did not go away. On 04/26/2023, R1’s Physician ordered a test to be conducted and R1 was prescribed antibiotics. Documents reviewed indicated that Facility communicated with R1’s Responsible Party on 04/28/2023 when R1’s antibiotics arrived and when they received their first dose. Reporting Party stated that it was observed R1 had distension in their stomach on 04/29/2023. Review of R1’s Hospital Notes,dated 04/29/2023, stated that distension was observed. Notes continued to state that R1 denied having any abdominal pain when asked and that R1 had a bowel movement on 04/28/2023, and passed gas that morning prior to their hospital visit. Review of R1’s Bowel Movement Chart indicated that R1 had a bowel movement the morning of 04/27/2023 and again on 04/29/2023. Reporting Party stated that Staff did not observe a change in R1’s legs. Based on interviews conducted, LPA received inconsistent information regarding the condition of R1’s legs and feet. Interviews conducted indicated that on the morning of 04/29/2023, Staff Member 1 (S1) observed R1’s legs and feet to be warm, red, and swollen. S1 reported the observation to Staff Member 2 (S2). S2 observed R1’s legs to be warm, red, swollen and that R1 had an elevated temperature when they went to administer a pain medication for them. S2 notified Facility’s Health and Wellness Director of their observations and asked R1 if they would like 911 to be called. R1 refused. Interviews conducted indicated that in the afternoon of 04/29/2023, S1 observed that R1’s legs were worse than they were in the morning while S2 observed that R1’s legs were in the same condition as before. Review of Facility documentation and incident reports indicated that R1’ s Responsible Party was contacted and informed of R1’s condition on 04/29/2023. Continued on LIC9099C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Continued from LIC9099C Review of Facility’s Clinical and Policy Procedure Manual states that “Facility staff are to notify the Health and Wellness Director or a Medication Technician when there is a resident change in status. A change in resident status can include the following: Elevated or subnormal temperature, wheezing, complaints of pain or discomfort, or change in skin integrity.” In addition, Review of R1’s Care Plan dated,05/22/2022, did not indicate a care need for R1 to have regular skin checks by the facility. This allegation is Unsubstantiated . There is an allegation that Staff did not respond to Resident’s Call cord. Report states that R1 pulled their call cord and no one came to assist them. Review of R1’s call light records for the months of March 2023 and April 2023 indicated that all calls were responded to within a time frame of 10 minutes or less. Staff interviews conducted stated that there haven’t been any concerns regarding the facility’s call light system and that it has been functioning appropriately. This allegation is Unsubstantiated. A finding that the Complaint Allegation is Unsubstantiated means 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. Exit interview conducted. Copy of report and LIC811 (Confidential Names) discussed and provided to Administrator. Signature on form confirms receipt of documents. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Continued from LIC9099 A finding that the Complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC811 (Confidential Names), LIC9099D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.