Sunshine Villa Assisted Living and Memory Care.

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced case management incident visit. LPA met with General Manager (GM) Candace Bolin. LPA stated the purpose of the visit. On 1/15/2026 the Department conducted a complaint investigation visit for an unrelated complaint. During interviews, it was alleged that a staff, referred to as S1, had inappropriately used a mirror while assisting a resident, referred to as R1, during toilet assistance, on an unknown date in 2025. On 1/15/2026, the Department interviewed 10 Residents (R1 to R10). 9 Out of 10 Residents stated he/she does not have any issues or concerns with staff. R7 declined to be interviewed . On 4/6/2026 the Department conducted an interview with Witness 1 (W1). W1 stated while helping R1 with care on an unknown date in 2025, R1 told him/her that S1 was helping with toileting, when R1 used a mirror to check R1’s private area. W1 states R1 stated he/she was ‘irritated’ due to S1 ‘giggling’ during the incident. W1 does not remember the date of the incident. W1 stated R1 did not provide additional information regarding this incident. W1 stated this incident was reported to facility management. On 4/17/2026 the Department interviewed Witness 2 (W2). W2 stated he/she spoke with R1 regarding the incident with S1. W2 stated R1 told S1 that he/she was having pain when using the bathroom. W2 stated S1 used a mirror to check R1’s private area. W2 stated he/she believed it was reasonable for R1 to use a mirror at that time. 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 W2 stated he/she reported this incident to facility management and did not know additional information regarding this incident. W2 stated he/she also spoke with R1 about the incident, but R1 did not provide additional information about this incident. On 4/28/2026 the Department interviewed Witness (W3). W3 states he/she was informed of the incident by W2. W3 states there was no documentation for an internal investigation into this incident. W3 stated he/she did not have any additional information regarding this incident. Review of R1’s Physician’s Report dated 1/22/2025, R1 is incontinent of bowel and bladder, unable to care for his/her toileting needs. R1 has major neurocognitive disorder. Review of S1’s file, there are no incidents noted regarding S1 being involved in abuse of residents in care. R1’s training record was reviewed, training records are dated 11/29/2023 to 1/1/2026, to include but not limited to dementia care, bladder care, incontinence care, and perineal care. On 5/14/2026, the Department reviewed Physician Fax Communications dated 12/27/2024, 12/30/2024, and 12/31/2024, which note the facility informed R1’s physician about R1 having bowel issues, with R1 requesting a change to his/her medications for bowel incontinence. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED . An exit view was conducted with GM Candace Bolin and a copy of this report was provided. Page 2 of 2 END OF REPORT

Licensing Program Analyst (LPA) Marcella Tarin arrived at the facility unannounced to conduct a case management – Other visit. LPA met with General Manager (GM) Candace Bolin. LPA stated the purpose of the visit. The purpose of the visit is to hand deliver an immediate exclusion letter for one individual (S1) who the Department determined engaged in conduct inimical. ADM stated S1 no longer works at the facility and was terminated on 3/12/2026. The immediate exclusion letter for S1 was handed to the GM. GM was informed to remove S1 from having any contact with residents and S1 was not allowed to be physically present in the facility. GM was advised to separate S1 from the facility roster. LPA requested a copy of the updated LIC 500 to be sent to CCL by 5PM on 4/13/2026. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with General Manager (GM) Candace Bolin and a copy of the report was provided.

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced Case Management visit regarding an incident that occurred on 3/7/2026. LPA met with General Manager (GM) Candace Bolin and Health Services Director (HSD) Heather Spears. LPA stated the purpose of the visit. On 3/9/2026 the Department received an Incident Report (IR) and SOC 341 regarding an incident between Staff S1 and Resident R1 that occurred on 3/7/2026. During visit, LPA obtained pertinent documentation to include but not limited to staff records, resident records, progress notes and staff schedule for 3/7/2026. LPA determined this incident requires further investigation. No deficiencies were cited during today's visit. An exit interview was conducted with General Manager (GM) Candace Bolin and copy of this report was provided.

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced Case Management to address an alleged incident of abuse of a resident reported during a complaint investigation visit. LPA met with General Manager (GM) Candace Bolin. LPA stated the purpose of the visit. During a complaint investigation visit on 1/15/2026, an alleged incident of abuse of a resident was reported. During visit, LPA interviewed GM, staff and residents. LPA reviewed staff training, and staff files. LPA requested pertinent documentation to included but not limited to staff training records, resident progress notes, and resident care plans. LPA determined this case management required further investigation. No deficiencies were cited during today's visit. An exit interview was conducted with General Manager (GM) Candace Bolin. A copy of this report was provided.

The Department interviewed 6 Staff (S1 to S6). 6 Out of 6 staff state there has never been a time a visitor was not permitted to visit with his/her loved one. The Department interviewed 2 Residents (R1 to R2). 1 Out of 2 residents state there has never been a time his/her visitors were not permitted to visit with him/her. R2 did not respond to questions due to neurocognitive disorder. The Department interviewed 3 Witnesses (W1 to W3). 3 Out of 3 Witnesses state he/she has no concerns about the care his/her loved one is receiving at the facility. Staff do not permit resident to leave the facility . The Department interviewed 6 Staff (S1 to S6). 6 Out of 6 staff state there has never been a time a resident was not permitted to leave the facility. The Department interviewed 2 Residents (R1 to R2). 1 Out of 2 residents states there has never been a time when the facility did not allow him/her to leave. R2 did not respond to questions due to neurocognitive disorder. The Department interviewed 3 Witnesses (W1 to W3). 3 Out of 3 Witnesses state he/she has no concerns about the care his/her loved one is receiving at the facility. Based on review of R1's physician's report dated 4/26/2024, R1 cannot leave the facility unassisted. Staff did not assist resident with obtaining medical care. It has been alleged by RP that the facility did not obtain care for R1's cracked lens on a pair of eyeglasses on 6/23/2025 to 6/25/2025 when RP visited with his/her loved one. The Department interviewed 6 Staff (S1 to S6). 6 Out of 6 staff state there has never been a time a resident was not assisted with obtaining medical care. 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 Department interviewed 3 Witnesses (W1 to W3). 3 Out of 3 Witnesses state he/she has no concerns about the care his/her loved one is receiving at the facility. W3 states the facility communicates when his/her loved one needs anything at the facility. This agency has investigated the complaint alleging staff do not permit resident to have visitors, staff do not permit resident to leave the facility, staff did not assist resident with obtaining medical care. 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 per California Code of Regulations, Title 22. An exit interview was conducted with GM Candace Bolin and a signed copy of this report was provided. Page 3 of 3 END OF REPORT

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced Case Management Incident visit. LPA met with General Manager Candace Bolin. LPA stated the purpose of the visit. On 10/6/2025 the facility reported a medication error that was discovered on 9/30/2025 for Resident R1, where a medication was discontinued on 08/15/2025 in error. The report states R1's physician and responsible parties were notified. During visit, LPA interviewed staff and requested pertinent documentation. LPA determined this incident requires further investigation. No deficiencies cited during today's visit per California Code of Regulations, Title 22. An exit interview was conducted with GM Candace Bolin and a signed copy of this report was provided.

Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to conduct a Case Management-Incident visit. LPA met with General Manager (GM) Candace Bolin. LPA stated the purpose of the visit. On 8/1/2025 the Department received an incident report and an SOC341 regarding an incident involving Residents R1 and R2 that occurred on 7/31/2025. The incident reports states R1 and R2 were involved in a physical altercation, and staff intervened. The incident report states no injuries were observed and residents were assessed after the altercation, and all responsibly parties were notified. The incident report states the facility will continue to monitor R1 and R2. LPA interviewed GM. GM states R1 and R2 are being escorted to his/her rooms by staff after activities to prevent another altercation. LPA requested pertinent documentation to include but not limited to residents physician's reports, and care plans. No deficiencies cited during today's visit per California Code of Regulations, Title 22. An exit interview was conducted with GM and a signed copy of this report was provided.

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced annual inspection and met with General Manager (GM) Candace Bolin. LPA stated the purpose of the visit. LPA toured the interior and exterior of the facility with GM to include but not limited to the kitchen, resident rooms, dining room, and kitchen. All exit and passageways were free and clear of obstruction. LPA toured the kitchen area and observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA observed the refrigerator temperature at 38 degrees F and Freezer at -15 degrees F. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. The facility was equipped with smoke and carbon monoxide detectors. The smoke detectors were last serviced and inspected on 3/25/2025. Fire extinguishers were last serviced on 9/13/2025. LPA reviewed the facility first aid kit, and it was observed to be complete. The facility emergency drill log was reviewed. The facility's last drill was on 6/28/2025, drills are being conducted monthly. LPA toured 10 resident rooms with GM. All 10 resident rooms have a bed, functioning lights, dresser/table, bedding and space for personal belongings. 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 toured 10 resident bathrooms. All 10 bathrooms had hand soap, paper towels, functioning lights, and covered trash bins. LPA measured water temperature in 10 resident bathrooms with a range from 105 degrees F to 118 degrees F. LPA toured the memory care with GM. LPA observed all exit and delayed egress doors in memory care alarmed, and functioned properly when tested by GM. LPA reviewed 5 resident records. Resident records included emergency contact information, physician’s report, needs and service plans, and personal rights. LPA reviewed 3 Resident’s Centrally Stored Medication and Destruction Records (CSMDR’s). LPA observed 1 medication for R2 was not written down on the centrally stored log. A Technical Assistance was issued, see LIC9120 for more information. LPA reviewed 5 staff records. Staff records included fingerprint background clearance, medical assessment with TB result, personnel record, and staff training. No deficiencies were cited during today's visit per California Code of Regulations Title 22. An exit interview was conducted with GM Candace Bolin and a signed copy of this report was provided. Page 2 of 2

Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to conduct a Case Management-Incident visit regarding an incident that occurred on 5/27/2025 and met with Health Services Director (HSD) Heather Spears. LPA stated the purpose of the visit. HSD stated General Manager (GM) Candace Bolin was out sick. On 5/28/2025 the Department received an Incident Report. LPA interviewed staff. During visit, LPA requested documentation to include but not limited to physician's report, service plan, and emergency contact information. LPA determined this case management requires additional review/information. No deficiencies cited today per California Code of Regulations, Title 22. An exit interview was conducted with HSD Heather Spears and a signed copy of this report was provided.

Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to conduct a Case Management POC visit to follow up on deficiencies cited on 4/4/2025. LPA met with General Manager (GM) Candace Bolin. LPA stated the purpose of the visit. ADM stated the facility has 101 residents and 48 staff. On 4/4/2025 LPAs Marcella Tarin and Manuel Monter conducted a Case Management visit to follow up on two elopements that were reported to the Department in December 202 4. Two deficiencies were issued and the Plan of Correction (POC) was developed with the GM. The POC was due on 4/5/2025 and was received by the Department on 4/4/2025. During visit, LPA reviewed documentation of staff training for 4/16/2025 to include topics of elopement, exit seeking behavior, communication and redirection ideas. GM states the facility will also be conducting another staff training on 4/23/2025 on elopements. The facility provided LPA with documentation of staff training for 4/16/2025 and 4/23/2025. LPA cleared the deficiencies cited on 4/4/2025 during today's visit. A Letter of Deficiency Citations Cleared was printed and provided to GM during today's visit. No deficiencies were cited during todays visit. An exit interview was conducted with GM Candace Bolin and a copy of this report was provided.

On February 28, 2025, LPA Manuel Monter interviewed staff S1-S6. Staff S1-S6 stated the Housekeeper cleans residents bedrooms once a week. S1-S6 stated the care givers are supposed to maintain the rooms clean during the week. 5 Out of 6 staff interviewed (S2-S6) stated they have not seen any bedrooms that are not clean or unsanitary or rooms that clearly are neglected and need to be cleaned. Staff S1 stated he/she has seen residents’ rooms that aren’t clean. S1 stated from his/her memory, he/she has seen two bedrooms as dirty/ that have been neglected. ADM stated resident bedrooms are cleaned weekly. ADM stated resident bedrooms Have assigned once a week housekeeping. ADM stated Care givers clean daily and remove trash each shift. ADM stated she has not seen any residents bedroom that were dirty, unclean or unsanitary. On February 27, 2025, LPA Manuel Monter toured the facility assisted living section of the facility and randomly toured the following bedrooms: 105, 111, 143, 206, 207, 217, 226, 230, 309, 315, 321, 410, 412, 423, 425. While touring these bedrooms, LPA Monter observed the bedrooms as clean, safe and sanitary. LPA Monter toured the following bedrooms in the memory care section of the facility: 1,3,5,7,9, 11. (Note all the bedrooms in the memory care are odd numbers by design.) LPA Monter observed the bedrooms as clean, safe and sanitary. On March 14, 2025, LPA’s Manuel Monter and Marcella Tarin interviewed residents R1-R10. LPA’s attempted to interview resident R1, but R1 did not respond to LPA’s questions. R1 would digress to unrelated topics. 9 Out of 10 residents (R2-R10) stated they have no issues with the apartments cleanliness and stated their living space is clean. LPA’s interviewed staff S7. Staff S7 stated housekeeping cleans residents’ bedrooms once a week. S7 stated If residents have an accident, then a care giver will clean the resident up and the area up. S7 stated, then housekeeping will come to sanitize the area as well. S7 stated he/she has not seen any resident bedrooms in an unclean/dirty state. S7 stated if he/she sees an accident in a residents bedroom, then he/she will notify staff to clean it up or he/she will clean it up herself. 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 On March 20, 2025, LPA Manuel Monter and Marcella Tarin toured the facility assisted living section of the facility and randomly toured the following bedrooms: 101, 103, 204, 218, 223, 247, 314, 333, 341, 345, 412, 414, 421. While touring these bedrooms, LPA Monter and Tarin observed the bedrooms as clean, safe and sanitary. LPA Monter and Tarin toured the following bedrooms in the memory care section of the facility: 1,3,5,7,9, 11. LPA Monter and Tarin observed the bedrooms as clean, safe and sanitary. Based on investigation, interviews conducted and records reviewed , the Department found that the above allegation is 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. Page 3 Out of 3. END OF REPORT.

Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to conduct a Case Management-Incident visit. LPA Tarin met with General Manager, Candace Bolin and explained the purpose of the visit. On 3/5/2025, the Department received an Incident Report and SOC341 for Resident R1 who was noted to have bruising on the left eye and sides of neck on 3/5/2025. The Incident Report states the neck bruising was discoloration due to 'dye transfer' from a necklace worn by R1 on 3/4/2025 and an unknown cause for the bruising on R1's left eye. The Incident Report states the facility sought medical care for R1, and all responsible parties and physician were informed about the incident on 3/5/2025. During visit, LPA interviewed 7 staff, observed R1 and toured R1's room. Based on interviews, the discoloration/'bruising' observed on R1 on 3/5/2025, was green dye that transferred onto R1's neck from beaded necklaces worn during a Mardi Gras event on 3/4/2025. Staff were able to wipe away the green discoloration from R1's neck on 3/5/2025. LPA did not observe bruising or discoloration on R1's neck during visit. LPA observed R1 to have bruising under the left eye. The facility does not know how R1 obtained bruising under the left eye on 3/5/2025. After this incident, the facility's plan of action is to provide more frequent checks on R1, including recognizing any areas of discoloration. The facility is also providing additional training for staff on recognizing bruising and discoloration. LPA requested the following documentation: photos from the events on 3/4/2025, R1's service plan and physician's report, staffing roster for 3/4/2025 and 3/5/2025. No deficiencies were issued during today's visit per California Code of Regulations, Title 22. An exit interview was conducted with General Manager, Candance Bolin and a copy of this report was provided.

Licensing Program Analysts (LPAs) Marcella Tarin and Manuel Monter arrived unannounced to conduct a Case Management-Incident regarding 2 elopements that occurred on 12/8/2024 and 12/15/2024. LPAs met with Administrator Candance Bolin and stated the purpose of the visit. During visit LPAs toured and tested the exit doors where R1 had allegedly eloped. LPAs interviewed 3 staff and the ADM. LPAs attempted to interview R2 who declined be interviewed. LPAs requested additional pertinent documentation and a copy of security video footage for elopements. Due to insufficient information, this investigation requires additional review. This report was reviewed with Administrator Candace Bolin and a signed copy of the report was provided.

Licensing Program Analysts (LPAs) Marcella Tarin and Kenneth Madrigal conducted an unannounced Case Management visit to follow up on two incident reports involving two elopements. LPAs met with Administrator Candace Bolin and explained the purpose of the visit. On 12/11/2024, the Department received an Incident Report regarding resident R1 eloping from the facility on 12/08/2024. R1 was returned back to the facility by local police and was unharmed during the elopement. On 12/18/2024, the Department received a second Incident Report regarding resident R2 eloping from the facility on 12/15/2024. R1 was returned to the facility by local police and was unharmed during the elopement. LPAs toured the interior and exterior of the facility and inspected the alarm panel in the Garden House Medroom for 13 alarmed exit doors in the facility. 13 out of 13 doors were alarmed, with all buttons on the panel indicating that the doors were alarmed. LPAs inspected Garden House Door #1 and Stairwell Exit Door #3, and Garden House Gate. LPAs interviewed 3 staff, and attempted to interview 2 residents during visit. LPAs requested R1 and R2's needs/service plan, R1 and R2's physician's report, staffing roster for 12/08/2024 and 12/15/2024, maintenance service records, a copy of security video footage and resident roster. Due to insufficient information, this investigation requires additional review. This report was reviewed with Administrator Candace Bolin and a signed copy of the report was provided.

Facility staff do not respond to the email of complaints from family members of residents: The allegation is that the facility Administrator did not respond to the email of complaints from family members of residents. On 5/28/2024, LPA interviewed Administrator (ADM) Candi Bolin. ADM stated he/she replied to all emails of complaints from family members of residents. ADM stated he/she was the second line to respond to the complaints or requests from the family member of residents before Health Service Director and Resident Care Director left the facility. ADM stated he/she received some enquiries from family members of residents regarding billings or request something after the 2 directors left the facility, and he/she replied to all of them. ADM stated he/she did not receive any complaint regarding care and supervision from family members of residents after the 2 directors left the facility. LPA interviewed the Facility Nurse (S1). S1 stated before the two directors left the facility, he/she was the second line to receive the complaints from residents or family members. S1 stated he/she did not receive any complain form residents or family members after the two directors left the facility on 5/21/2024. On 11/17/2024, LPA called two family members (FM1, FM2) of residents and left message. LPA did not any response back. Based on the interview, there is no evidence to indicate the facility Administrator did not respond to the email of complaint from family members of residents. Facility does not have directors of health service and resident service to manage and supervise caregivers to provide care and supervision to residents: On 5/28/2024, LPA interviewed Administrator (ADM). ADM stated the facility Health Service Director and Resident Service Director left the facility on 5/21/2024, and the two position are still vacancies. ADM stated the facility is seeking for candidates to fill the two positions. ADM stated he/she and the Facility Nurse S1 share the workloads of the two directors. ADM stated a Med Tech (S2) is assigned as Head of Med Tech to schedule and group Med Techs and Caregivers to provide care and supervision to residents which was part of the two directors' workload. Continue on LIC9099-C. 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 ADM stated a Health Service Specialist (S3) from corporate comes to the facility today to help him/her to operate the facility. ADM stated there is no impact on the facility to provide care and supervision to residents. LPA interviewed the Facility Nurse (S1). S1 stated he/she, ADM and Head of Med Tech S2 share the workload of the two directors who left the facility on 5/21/2024. S1 stated there is no impact for the leaving of the two directors. LPA interviewed the Head of Med Tech S2. S2 stated he/she schedules and groups Med Tech and caregivers to provide services to residents, and he/she also conducts the work of Med Tech when he/she is available. S2 stated he/she can handle it and there is no impact for the leaving of the two directors. LPA interviewed the Health Service Specialist from Corporate (S3). S3 stated he/she comes to help the facility. S3 stated his/her job is to make sure residents receive good care and to audit the facility. LPA interviewed another 3 staff. 3 Out of 3 staff stated there is no impact for the leaving of the 2 directors. LPA interviewed 8 residents. 8 Out of 8 residents stated they do not have complaint against the facility. 2 Out 8 residents stated they there is no impact for the leaving of the 2 directors. 6 Out of 8 residents stated they don't know if any of the facility director left. Based on the interview, no evidence to indicate the facility has impact to provide care and supervision to residents due to 2 directors left the facility. Based on investigation, interviews conducted and records reviewed , the Department found that the above allegation is 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 citations noted at today’s compliant investigation visit. Exit interview conducted with ADM. A copy of this report was provided to ADM. Page 3 of 3.

Allegation were made that the facility is not quarantining residents who test positive for COVID-19. The investigation included a review of records and interviews with residents and staff. The facility's Mitigation Plan, dated January 14, 2021, was also reviewed and is within the CDC guidelines. LPA Lee interviewed all 7 residents, none of whom expressed concerns about the facility's quarantine practices for COVID-19 positive residents. Residents indicated that those who test positive are required to quarantine in their rooms. Additionally, LPA Lee spoke with all 3 staff members, who confirmed that the facility adheres to CDC guidelines and denied the allegation. Based on the interviews and evidence collected during the investigation, LPA Lee was unable to corroborate the allegation that facility is not quarantining residents who test positive for COVID-19. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred.

According to the same statement that RP provided, the facility did make a note about the occurrence on May 19, 2023, when they found R1 that way. They have banned the resident assistant that was supposed to help R1 that night. Based on records review, the facility provided the LPA with Progress Notes. In these progress notes, the facility was already observing R1’s changes in conditions. A new assessment was done on April 27, 2023. In this assessment, it was noted that R1 is at risk for injury which may cause permanent disability or be life threatening. The following interventions/practices are recommended to enhance the safety of your family member. Reminders to use call system for needed assistance. Also in these progress notes from April 2023 – May 2023, it is noted in several entries that R1 has been eating less and less and has been experiencing pain and was being monitored continuously. R1 was entered into hospice on May 24, 2023. Regarding the allegation of Staff are not following medication orders, RP observed two of the medication technicians did not follow the orders. One staff member (S1) brought a 5 mg Valium and called it a hydrochlorothiazide. Another medication technician (S2) brought a whole Vicodin when the orders were to crush it into applesauce, but S2 brought the entire pill. Based on records review in the progress notes, on 05/23/2023 9:48AM (Late Entry) states that R1s family member (F1) gave R1 a Vicodin medication and is not on R1s med list. R1s MD was faxed, and a staff member (S3) is aware and R1 will be monitored for any allergic reactions or behavior changes. LPA was also able to obtain this report. Regarding the allegation that Facility is not safeguarding resident's personal belongings, RP stated that there is also a thief there that stole from R1 in December when R1 first moved in, a very valuable diamond ring and then on R1s deathbed, gold chain with charms. LPA spoke to the Executive Director (ED), and it was stated that the facility did an internal investigation and did not find any proof that a staff stole the valuables. 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 Regarding the allegation of Facility is not maintaining a comfortable temperature for residents in care, RP stated that they had to ask facility to put an air conditioner in and it took weeks even though RP offered to buy it. R1s room was 90° on Easter even though the thermostat was set on 50°. During the interview, ED mentioned that the facility has not reached that temperature. While the rooms don’t have air conditioning system, the facility does have portable aircons which they can provide to residents if requested. According to RP, although it took quite some time, the facility did provide air-conditioning in the room. Based on interviews & records review, the department has determined that 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, therefore the allegation is UNSUBSTANTIATED. Report is reviewed and copy is provided. page 3 of 3