Pacifica Senior Living Union City

On 6/30/2021 starting at 11:55am, Licensing Program Analyst (LPA) L. Francisco and Staff Services Analyst (SSA) S. Vincent arrived unannounced to conduct an Infection Control Inspection. LPA and SSA met with Administrator, Ramandeep Kaur and explained the purpose of the visit. During the Infection Control Inspection, LPA and SSA toured facility with Administrator including but not limited to front entrance, screening station, hand washing stations, apartments, common areas, activity rooms, kitchen and courtyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed throughout facility. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has a mitigation plan and maintains record of routine screening for residents and staff. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

On 8/16/2021 at 1:01PM, Licensing Program Analysts (LPAs) G. Luk and G. Clark arrived unannounced to conduct a case management inspection in regards to incident report received on 8/9/2021. LPAs met with Executive Director, Rammy Kaur. Incident report dated 8/9/2021 revealed that R1 AWOL and facility notified law enforcement and R1's responsible party. R1 was found by police and was taken to Kaiser Hospital. Interview with S1 revealed that R1 left the facility during the evening time when staff was exiting the building. S1 stated R1 was found by the police and taken to Kaiser Hospital. Family member took R1 back home and returned to the facility on Friday. During record review, LPAs observed that physician's report dated 4/1/2021 stated that R1 cannot leave the facility unassisted. The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalty. Exit interview conducted. A copy of this report and appeal rights provided.

Allegation: Staff are not properly trained to administer medications - UNSUBSTANTIATED It was alleged that the Staff are not properly trained to administer medications. However, during the investigation, LPAs reviewed the Med Tech schedule for May, June, and July 2024. S2, S7, S8, and S9 were scheduled as Med Tech during May, June, and July 2024. The record reviewed shows that S2, S7, S8, and S9 have all completed their training on record. Allegation: Lack of supervision resulting in resident sustaining a fall - UNSUBSTANTIATED It was alleged that the facility lacks supervision, resulting in a resident sustaining a fall. During the investigation, LPAs reviewed the R2 physician report, R2 assessment, the time R2 moved in and after the sudden fall. At the time of the incident, R2 was receiving appropriate supervision according to the R2 assessment. R2 assessment dated 12/17/2023 – 5/23/2024 shows R2 ambulates independently. R2 had a sudden fall on 6/24/2024 facility updated R2's needs and services plan after the fall, dated 6/25/2024, indicated that R2 will be checked every two hours before and after bedtime on going. Allegation: Facility is not ensuring a staff is on duty on the premises overnight- UNSUBSTANTIATED It was alleged that the facility is not ensuring a staff in on duty on the premises overnight. During the investigation, LPAs reviewed the staff schedule for May 2024 to the current shows the facility has staff on duty on the premises overnight. LPAs conducted staff and resident interview confirmed that there are staff on duty on the premises overnight. Although the allegation 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. Exit interview conducted and a copy of this report provided.

Page 2 LPA obtained copies of staff schedules, LIC501 Personnel Records and resident roster. LPA also interviewed the following: staff (S1, S2) and former Executive Director (FED) on 11/28/23; resident’s family member (W1) on 12/05/23; R1 and R3’s family member (FM1) and staff (S3 and S4) on 5/27/25. Allegation: Questionable death. It was reported that resident (R1) passed away on 11/19/23 because the facility did not seek timely medical assistance. S1 stated when she went to R1’s room sometime between 11/06/23 and 11/08/23 and observed R1 pale and not responsive, she called 9-11. R1 was sent out and diagnosed with infection. Records confirmed R1 was sent out to the hospital. Records also showed R1 was placed on hospice on 11/10/23 with terminal diagnosis of cerebrovascular disease. Death certificate showed immediate cause of death as cerebrovascular disease, Parkinson’s disease, adult failure to thrive and no other significant conditions contributing to R1’s death. Based on information gathered, the allegation is closed as unsubstantiated. Allegation: Staff are not assisting residents with bathing needs. S1 stated that R2 has not been showered for a month. S2 indicated that bathing is included in the resident’s Care Plan and the frequency depends on the Care Plan. S3 and S4 stated they give bath to residents 2 times per week. FM1 stated she visited R1 and R3 when they were at the facility and stated R1 and R3 were bathe 2 times per week. Review of bathing schedules showed R1 on the list on a once-a-week schedule. R2 was listed on twice-a- week schedule. LPA was not able to interview R1 and R3 due to these residents were no longer at the facility when complaint was received. Due R2’s medical diagnosis, LPA was also unable to obtain information. LPA tried to reach R2’s responsible person but was unsuccessful. Therefore, the allegation is unsubstantiated. .......continued on 9099C (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 Allegation: Residents are left in soiled clothing for an extended period of time. S1 stated that R2 was often left in soiled clothing for hours and not provided care due to R2 has been deemed by the caregivers as a difficult resident. S1 also stated that when she was assigned to Memory Care, she observed R2 wore the same clothes from previous day. S2, S3 and S4 stated residents’ clothing are changed every day. FED stated that it was never brought to his attention about the issue. FM1 stated she never observed R1 and R3 in soiled/uncleaned clothes. W1 also stated not observing her mother in soiled clothing and when her mother felt wet, the caregiver came right away. LPA was not able to interview R1 and R3 due to these residents were no longer at the facility when complaint was received. Due R2’s medical diagnosis, LPA was also unable to obtain information. LPA tried to reach R2’s responsible person but was unsuccessful. Therefore, the allegation is unsubstantiated. Allegation: Staff are not ensuring that residents have clean clothing. S1 stated there were times she observed R2 not wearing undergarment and socks. S1 further stated that when she asked the caregivers, she was told that R2 did not have clean clothes. S2 stated there was never an incident where resident run out of clean clothing. S2 further stated that if they see residents do not have enough for the week, they communicate. S3 and S4 stated that residents assigned to them never run out of clean clothes. FED stated the issue was never brought to his attention. FM1 and W1 stated their love one never run out of clean clothes. LPA was not able to interview R1 and R3 due to these residents were no longer at the facility when complaint was received. Due R2’s medical diagnosis, LPA was also unable to obtain information. LPA tried to reach R2’s responsible person but was unsuccessful. Therefore, the allegation is unsubstantiated. ......continued on 9099C (page 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 Page 4 Allegation: Staff are not assisting residents with refilling their prescriptions. S1 stated that R2 and other residents were missing medications because the medications were not refilled. S1 further stated that according to S5, R2 was not receiving medications because R2's responsible person (FM2) was not picking up the phone when they call. S2 stated the med-techs are in-charge of medications including refills. S2 further stated that the cycle of med refills is every 2nd of the month to ensure residents never run out of medications and that 15 days before medications run out, the med-tech take care of refills. S3 and S4 stated the med-techs are in-charge of medications. W1 stated her mother never run out of medications and that the staff were very good in calling and telling her when her mother is running out of medications and refills were done right away. LPA tried but unable to obtain information from S5 and FM2. Therefore, the allegation is unsubstantiated. Based on interviews and records review, the five allegations are closed as unsubstantiated. A finding that the complaint is 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 violations occurred. No deficiency cited. Exit interview conducted and copy of this report provided.

Page 2 Allegation: Resident (R1) sustained unexplained bruising while in care. R1's family member (FM) stated that on 5/10/22, FM reached out to the assistant director regarding an incident where R1 ended up crying at the end of R1's shower and the next day the nurse found bruising on R1's shoulder and arms. LPA reviewed the documents from Pine Park Health, a third party that provides medical services to the residents in the facility. Pine Park's records and visit notes for R1 from 1/26/22 to 6/22/22 didn't show any note indicating R1 had bruising. Facility's Narrative Charting of communication with R1's responsible person and R2 (R1's husband) for R1 for 1/10/22, 1/13/22, 1/29/22, 2/16/22, 2/22/22, 3/14/22, 3/30/22 and 6/15/22 had no information pertaining to bruising. There's no UIR regarding bruising. LPA could not interview R1 and R2 since they were longer at the facility. Based on information gathered and LPA unable to obtain information from R1 and R2, the allegation is closed as unsubstantiated. Allegation: Residents not provided a pendant. FM stated that R1 and R2 did not have pendant for 4 days because it was broken. S1 and S2 stated R1 and R2 had pendant. S1 stated she does not recall R1 and R2 not having pendant for days. S2 stated it's always R2 who pressed the pendant when help was needed. S3 and S4 stated the residents in Assisted Living (AL) are provided pendants but not the residents in Memory Care (MC). When pendant is not working or broken, it is replaced same day. These statements were confirmed by LPA with ED. ED stated only residents in AL are provided pendant. ED further stated that residents in MC are not given pendants because staff do more supervision. If the pendant is broken, it is replaced the same day. The facility has at least 6 extra pendants. .....continued on 9099C (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 R3 and R4 stated they have pendants. R3 stated she seldom use hers while R4 stated the pendant is working and the staff check it regularly. Based on information obtained and LPA unable to obtain information from R1 and R2, the allegation is closed as unsubstantiated. Allegation: Facility does not have an administrator during hours of operation. When LPA conducted an initial complaint visit on 6/24/22, LPA met with interim Administrator Mandy Taylor. Ms. Taylor has valid administrator certificate. S1 stated never was a time where facility has no executive director (ED)/administrator. If the ED quits and the corporate is in the process of hiring, the Regional Director serves as interim administrator. S2 stated the facility has always administrator to talk to. R3 and R4 stated there's always administrator and staff available. Based on information obtained and LPA unable to obtain information from R1 and R2, the allegation is closed as unsubstantiated. A finding that the complaint is 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 violations occurred. No deficiency cited. Exit interview conducted and copy of this report provided.

Facility does not have sufficient food available for their anytime menu. Interview with residents revealed that they are able to order from the "Always Available Menu". Interview with staff indicated that sometimes food distributors would be out of stock on certain food items on that menu. LPA observed facility have sufficient perishable and nonperishable items available. Staff does not treat residents with dignity. Interview with residents and staff revealed that staff treat residents well and are friendly to residents. Residents stated they have not witness staff mistreat residents. Staff would retaliate against residents who complaint of facility services. Interview with residents revealed that staff did not retaliate against residents. Interview with staff indicated they have not witness staff retaliate against residents and would treat residents the same. Facility is not providing nutritional food resulting in resident loosing weight. Interview with staff indicated the facility provides nutritional foods to residents and was not aware any residents loose weight due to poor nutrition. There was a lack of information provided regarding the resident who loose weight due to not provided enough nutritional foods. Insufficient staffing Interview with staff indicated the facility has sufficient staffing which includes 2-3 staff for morning and afternoon shift, and 2 staff for night shift. Interview with residents revealed that majority of residents felt the facility had enough staff. Resident is paying for services that's not being provided. R1's care plan indicated that R1 needed standby assist with bathing, partial assist with transfers, escort R1 to meals/activities, and special diet which was a level 4 care. However, R1's detail ledger revealed that R1 was charged for level 2 care which did not include most of the services in R1's care plan. (Continue 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 Facility is not following resident's diet per doctor's order. R1 had a diet order form which indicated that R1 is on a mechanical soft diet. Interview with staff revealed that residents with special diets are identified in the kitchen area. S3 stated that staff have provided mechanical soft meals for R1, but R1 didn't want the food and sent it back. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore these allegations are UNSUBSTANTIATED . No deficiencies are being cited on this date. Exit interview conducted. A copy of this report provided.

Page 2 Allegation: Resident (R1) in care sustained unexplained medication overdose. FM1 stated that R1 was admitted to the facility on 1/10/23. On or around 1/15/23, S1 called FM1 and informed FM1 that R1 was refusing to eat and participate in activities. Approximately 4 to 5 days after admission, FM2 received a call from facility staff saying R1 was not eating, drinking, or getting out of bed. FM2 stated that on or around 1/20/23, FM1 and FM2 received a call from S1 informing that R1 will be send out to the hospital. Prior to arrival to the hospital, the Emergency Department (ED) doctor called and told FM1 and FM2 that R1 was poisoned by Lithium and that R1 was dehydrated. Medical records showed R1 was brought into the hospital on 1/21/2023 with Lithium toxicity and an acute kidney injury. The lithium toxicity caused R1 to have an altered mental status while the acute kidney injury was caused by poor food/fluid intake. R1 refused to take her medications at various times on 1/13/2023, 1/14/2023, 1/19/2023 and 1/21/2023. Staff who were interviewed all stated R1 refused to do anything, refused to get out of bed and refused to eat and drink throughout her stay at the facility. Resident Services Director (RSD) assessed R1 at home prior to R1’s admission and R1 was independent and able to do a lot of things on her own. However, after R1’s admission, R1 changed, became depressed and only wanted to stay in bed. R1’s refusal to get out of bed, eat and drink and do anything contributed to her condition leading her to be hospitalized. R1 stated she had been taking Lithium for over 5 years. R1 admitted not eating and stated that staff brought food to R1’s room and tried to be feeding her but does not remember if she drank fluids regularly while at the facility. The medical records confirm that R1 was admitted for lithium toxicity. The medical records do not indicate a cause, however, FM1 stated that lithium must be accompanied by adequate liquid intake, otherwise it accumulates in the body. Staff reported that R1 was not eating and drinking regularly. It was found that R1 had medication orders for the lithium and the facility’s Centrally Stored Medication and Medication Administration Records were in order. The facility med-tech stated having provided all medications as ordered by the primary care physician (PCP). Therefore, the allegation is unsubstantiated. ....continued on 9099C (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 Allegation: Resident (R1) became severely dehydrated while in care. All staff interviewed stated R1 refused to eat and drink during the 11 days R1 resided at the facility. R1 had two sips of an 8 ounce cup of water when her medication was administered to her. Staff noticed that R1’s water cup and water pitcher were barely touched. R1 drank juice that was offered to her and ate approximately 15%-25% of food that was served to her. All staff stated having made attempts to encourage R1 to eat and drink during her meals, even feeding her. R1’s refusal to eat and drink contributed to her worsening condition. Staff noticed R1 had cracked lips and was not eating or drinking much. They knew R1 needed water/fluids for her medications. R1 stated she had been taking Lithium for over 5 years. R1 also stated that Lithium is a form of salt and taking this medication would require one to drink a lot of water to have it released from one’s body. R1 admitted to not eating and drinking consistently and stated that staff brought food and liquid to R1’s room and tried feeding her but does not remember if she drank fluids regularly while at the facility. No information emerged to indicate that staff were not attempting to have R1 drink liquids. Therefore, the allegation is unsubstantiated. Based on records review and interviews, both allegations are unsubstantiated. A finding that the complaint is 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 violations occurred. No citation issued. Exit interview conducted and copy of this report provided.

Although the allegation 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. Exit interview conducted and a copy of this report provided.

On this day, 1/09/25, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management visit resulting from a complaint (Complaint Control # 15-AS-20230209091605) investigated by the Department. LPA met with Executive Director (ED) Marie Lagasca-Cruz, and informed the purpose of visit. During investigation, the Resident Services Director (RSD) stated she advised R1’s sister via telephone on 1/14/23 that R1 was not well and was going to send her to the hospital. Between 1/14/23 through 1/21/23, R1 was weak, refused to eat on some days, and barely able to stand up. Other days, R1 was responsive and requested foods but ate very little. During RSD’s interview, RSD stated R1’s sister declined to have R1 sent to the hospital, but RSD did not agree. Previous Assistant Executive Director stated staff are to report concerns to the resident's doctor when families decline. There was no communication with R1’s doctor for the date of 1/14/2023, and R1 was not sent to the hospital until 1/21/2023 – a week later. Deficiency is cited per Title 22 California Code of Regulations, and listed on LIC809D. Failure to submit proof of correction by plan of correction due date, and any repeat violation within 12 month period may result in civil penalty. Deficiency and plan and proof of correction were discussed with the ED. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.

On this day at around 2:10 pm, Licensing Program Analyst (LPA) K. Nguyen conducted a case management visit in connection with an 30-day termination notice of R1. LPA met with Resident Services Director, Marissa Baldomero and explained the purpose of the visit. LPA received an 30day termination notice in regrade of R1 not being able to pay. R1 is still reside at the facility. S1 stated R1 have not pay the facility since February 2024. The letter indicated that the notice effective date is June 14, 2024, due to the outstanding amount of 7,321.67. S1 stated that R1 family is aware of the situation, and family didn’t say anything. R1 is not reserved, no POA, and R1 makes own decision, and R1 is the full payee. Facility is in the process of eviction but is waiting for the judge to make the final decision. S1 stated R1 told them R1 knows that R1 owe money but doesn’t want to pay, and is waiting to be evicted. No deficiency was noted during the visit. A copy of this report was provided.

Continued from LIC9099. submitted to CCLD, which indicated R1 had complained of pain to his arm to his family member on 3/18/2022, where R1 slid from his chair onto the floor. Per incident report R1 stated the incident occurred two weeks prior. R1 also stated at the time of the incident he refused help from the two (2) staff that came to assist. S1 stated during interview that protocol is for staff to inform the director of the incident in a timely manner. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of the appeal rights and this report 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 Continued from LIC9099. and fell when trying to independently transfer from bed to wheelchair. Review of Kaiser of San Leandro medical records dated 3/19/2022, indicated R1 sustained a fracture to his right humerus bone while transferring from his wheelchair to his bed. At the time of admittance to the facility and at the time of the injury, R1 was independent and able to transfer between his bed and wheelchair. Based on record review, R1 was listed as ‘independent’ and did not require transfer assistance from and to bed from the wheelchair. Allegation: Staff did not ensure that resident was adequately fed W1 stated that R1 was able to wheel himself around but didn’t want to. R1 wanted staff to wheel him downstairs to the dining area. W1 stated there were times that staff would come to assist R1, but it was too early for R1 to eat. Department reviewed charting notes from facility that indicated R1 refused dinner several times due to R1 had food or snacks in his room. Per R1's assessment R1 required reminders for meals not to be escorted. Allegation: Staff did not provide resident showers according to the resident's Admission Agreement Based on interview with W1 showers were to be given to R1 Friday’s at 1pm and R1 would refuse if showers were not timely. W1 stated the facility was aware of this before R1’s admission. Review of admission agreement indicated facility will provide assistance with bathing. Review of R1's assessment dated 11/29/2021 indicated R1 required a one (1) person assist per week for bathing. Department did not 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. observe any documentation that was agreed upon between R1's responsible party and the facility that showers will be given at a specific time. Per S1 staff would try to accommodate R1's request for the time of shower but it was not always possible due to assisting other residents. All egation: Staff did not keep resident's room clean or sanitary Based on initial interview with W1 staff did not keep resident’s room clean or sanitary. During interview with W1 on 12/2/2024, W1 stated there was not an issue with R1’s room being cleaned. W1 saw the housekeeper a few times while visiting. Allegation: Facility call system was not accessible to resident Based on interview with W1 the call pendent R1 was given was usually broken. W1 stated when the pendent wasn't working staff would come and take it, but wouldn't get it replaced for a couple of days. During interview with S1 if a pendent was not working or low battery the system will notify staff and a new pendent will be give. S1 stated the pendents can not be fixed. The facility keeps pendents available. S1 pulled a call log from the archives dated 3/13/2022 - 3/31/2022, which divulged R1 had used pendent six (6) times during that period. The dates the pendent was used was 3/13, 3/14 (2xs), 3/16, 3/17, and 3/18. Based upon the interviews conducted and information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit interview conducted and a copy of report was given .

On this day at around 1:10 pm, Licensing Program Analyst (LPA) K. Nguyen conducted a case management visit in connection with an incident reported by the facility. LPA met with Resident Services Director, Marissa Baldomero and Operation Specialist, Kathy Valencia and explained the purpose of the visit. LPA received an UIR dated on 9/17/24 regarding an elopement. LPA interviewed S1 stated on the day of the incident staff walked R1 on a daily routine to visit R1 wife (lunch and dinner). R1 decided to take a walk and R1 wife cannot stop R1 from taking a walked. After R1 took off the wife called the front desk and informed us that R1 had taken a walk. S1 stated that this is a new behavior for R1 to walked off from R1 wife apartment. S2 stated that it was an agreement between the family and the facility to have R1 visit his wife on a daily routine. After R1 wife informed us we immediately send out staff to search for R1 and found R1 near senior center. S2 stated that the care plan has been update to R1 wife go to visit R1 in memory care. S1 stated that R1 wife stay in Assisted Living so when R1 took off there was no alarm that went off, due to assisted living unit. S2 is keeping a close communication with R1 family members. No deficiency was noted during the visit. A copy of this report was provided.

On this day at around 3:00 pm, Licensing Program Analyst (LPA) K. Nguyen conducted a case management visit in connection with an incident reported by the facility. LPA met with Administrator, Jeralyn May and explained the purpose of the visit. LPA interview S1 regrading the incident. S1 stated that the gate that was supposed to be lock was not lock that led to an elopement. During the time resident was led outside by Activity assistance for an activity. The staff didn’t notice that the resident had went outside the gate. The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.

On 10/21/24 at approximately 2:15 pm, Licensing Program Analyst (LPAs) K. Nguyen and L. Alexander conducted a case management visit pertaining to a letter received by the Oakland CCL ASC Regional Office from the facility. LPAs met with Executive Director(ED), Marie Lagasca and explained the purpose of the visit. On July 11, 2024, the Oakland CCL ASC Regional Office received from the facility a letter of intent to delicense the third floor of the physical plant and convert those units for Independent Individuals who are 55 years of age and older. The letter did not specifically request approval from CCL and had insufficient detail pertaining to how the co-mingling of Independent aged 55+ renters, and licensed RCFE Assisted Living residents, would be managed to ensure the Health & Safety of the Assisted Living residents. LPAs interviewed the ED, stated that the facility has not and are not accepting any independent living resident at this time. The ED informed the LPAs that the facility is advertising for 55+ independent persons but nit accepting any for residency, per need for approval from CCL. On 10/16/24 LPM Jeremy Fong and on 10/21/24 LPA Kelly Nguyen and ED confirmed that the facility’s website is advertising for independent renters aged 55 and older, which constitutes a change to the Plan of Operation without having obtained approval from Community Care Licensing. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.

LPA K. Nguyen conducted an unannounced case management visit to serve an immediate exclusion order to staff S1. LPA K. Nguyen first spoke privately with Executive Director Rob Roby to explain the situation - providing him with a copy of the Order to Executive Director of Immediate Exclusion. According to Executive Director S1 haven’t been at the facility since May 16, 2024, also is terminated from our facility. LPA K. Nguyen reviewed this report with Executive Director, and a copy of this report is provided via email.

LPA interviewed R1, R1 stated R1 does not recall the time frame of the event. R1 stated that nothing happened to R1. LPA interviewed S1, S2, S3, S4, S5, and S6 all indicated that they noticed that R1 memory have be declining alot and is on a lot of medication that might cause R1 to hallucinate. S6 stated that the polices officer spoke to S6 whom was investigating this incident indicated that he believes/ observed that R1 is hallucinating, because R1 is telling two different stories, and R1 doesn’t remembered. Although the allegation 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. Exit interview conducted and a copy of this report provided.

It was alleged that Staff did not provide a safe and comfortable environment Based on observations, LPA observed the facility to be safe and comfortable for residents. Based on interviews with residents (R1, R2 and R3) residents felt that they were safe and comfortable, residents stated they have had no issues with staff and that staff are very nice. Based on interviews with staff (S1) residents have not expressed feeling unsafe or uncomfortable. S1 stated that they have not observed a resident being treated unwell and that staff ensure to take care of the residents. Based on LPA observations, interviews, although the allegation 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 . Exit interview conducted and a copy of this report 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 It was alleged that Facility has mold Based on interview with Maintenance Manager (MM), if mold/mildew was present and reported to facility staff it would be treated in house. MM stated that they would inspect the area, relocate the resident residing in area and treat it with cleaners such as bleach. Based on documentation review, there was evidence of mold located in a resident’s apartment and mold treatment was required. Based on interviews with staff (S3 and S4) mold has been observed in various apartment’s in residents AC units and closets by staff and residents residing. S3 stated that they have reported their observations to facility management and noticed AC units were replaced recently. S3 believes mold is throughout the facility still despite facility management changing AC units. Based on LPAs interviews and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted. A copy of this report and appeal rights provided.

While LPA K. Nguyen was at the facility for a one annual inspection, the following deficiency were observed. After touring the memory care unit, LPA observed residents where being lock inside their room. In memory care unit there is a door that is lock cannot open without the key. That door led to the resident door that is looked as well. LPA observed that the resident was being locked inside, while still eating breakfast. The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.

On this day, November 28, 2023, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a health and safety inspection as a result of the Department receiving a priority 1 complaint (Complaint # 15-AS-20231122143232). LPA met with Executive Director (ED) Robert 'Rob' Roby and Assisted Living Director Shenina Robinson-Mason. LPA toured the facility including but not limited to common areas, dining rooms, medication room, activity rooms/areas, and bathrooms on the first and second floors. LPA observed the medication room open and attended by a med-tech. LPA randomly selected for inspection a total of 5 resident rooms on the first and second floors. During review of 4 residents records, LPA observed no Death Report and Unusual Incident Report (UIR) for 1 of the residents. Deficiencies are cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of corrections by plan of correction due dates, and any repeat violation within 12 month period may result in civil penalties. Deficiencies were discussed with ED. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.

Based on information obtained, the preponderance of evidence is met, therefore. the allegation is substantiated. Deficiency is cited from Title 22 California Code of Regulations, and listed on 9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violation within 12 month period may result in civil penalty. Deficiency and plan and proof of correction were discussed with the ED. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form, and copy of this report 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 Based on information obtained, the allegation is unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that a violation occurred. No deficiency cited. Exit interview conducted and copy of this report provided.

Continued from LIC9099. having a conversation regarding R1's eyeglasses and receiving an invoice for $14. ED also stated that R1 was sent a closing invoice that refunded him $2872.58, but it doesn't itemize the refunded charges. Record review of admission agreement on page 7 section IV states facility is not responsible for furnishing or paying for eyeglasses, and page 17 section F stated facility is not responsible for the loss of any personal property unless loss or damage was caused by negligence of employees. Based on interviews it was not indicated that staff was responsible of losing the eyeglasses. The eyeglasses were found but they were broken. Although the allegation 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. Exit interview conducted and a copy of this report provided.

On 10/4/2023 at 4:30PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit. LPA met with Executive Director, Robert Roby. While LPA G. Luk was at the facility for a complaint investigation (#15-AS-20230925101546), the following deficiencies were observed. After touring the kitchen, LPA observed chemicals for floor repairs were stored in the kitchen area. Staff removed the chemicals and put them with other cleaning supplies room. At around 4:45PM, LPA observed a tray of bacon was stored in the walk-in refrigerator without any covering/wrapping. LPA observed other containers with loosely covered wrappings. Staff discard bacon during inspection. The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.

Memory Care Director and staff interviewed state residents who are incontinent get changed every 1-2 hours. They also state they are aware which residents are incontinent and needed to be changed regularly. Staff interviewed also state that they make sure each resident wears clean clothes all the time. And that they check on residents' clothes especially after meals for food spills. Memory Care Director states R1 moved out of the facility a few days prior to LPA visit due to the increase in level of care fees. On 5/4/2023, LPA interviewed R4, R5 and R6. R6 states that staff are good. R6 added that staff come to assist if needed. LPA attempted to interview R4 and R5 . Due to dementia diagnosis, LPA was unable to interview R4 and R5. Based on interviews conducted, the above allegations are unsubstantiated. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

On 5/23/2022, R1 wandered away from the facility. Based on the call record provided by RP, RP was informed about the incident at around 6:33 pm. RP was told by facility that R1 was observed missing at around 4:45 pm. At around 6:38 pm, RP states that a friend texted RP about R1 spotted around Niles area of Fremont which is approximately 4.4 miles away from the facility and has a walking time of approximately 1hr and 36 minutes. At around 7:15 pm, RP found R1 near the corner of Mission Blvd and Walnut Avenue in Fremont. A copy of Union City Police Department Everbridge Nixles missing person report was obtained and indicates that the incident was entered on 5/23/2022 at 7:41pm. A review of facility’s three internal incident reports confirm that R1 wandered away from the facility on May 23, 2022. Staff are mismanaging resident's medication LPA L. Fontanilla obtained and reviewed R1’s April - May 2022 Medication Administration Record (MAR). April 2022 MAR indicates R1 was on Donepezil from April 22-30. For the month of May, R1 was given the medicine on May 3,4,7,8,9,11-14 for a total of (9) days only. Based on records review conducted, the above allegations are substantiated. Based on record reviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations Title 22 are being cited on the attached Lic 9099D Exit interview was conducted with Director and Appeal Rights 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 Resident’s room has pests During the course of investigation, LPA interviewed Robert Roby. He states the facility has a contract with Ecolab Pest Control. On 7/19/2023, LPA inspected four rooms in the Memory Care Unit and did not observe any pests in the rooms. MCD denied seeing any pests in any of the rooms in the Memory Care Unit. Based on observation and interviews conducted, the above allegations are unsubstantiated . Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

On this day at around 3:05 pm, Licensing Program Analyst (LPA) Luisa Fontanilla conducted a case management visit in connection with an incident reported by the facility. LPA met with Executive Director Robert Roby and explained the purpose of the visit. During the visit, LPA obtained Resident 1 (R1) Physician's Reports, Needs and Services Plan and Hospital discharge papers . LPA reviewed records and interviewed Staff 2 (S2) and Resident 1 (R1). Based on R1's Physician's Report (PR) dated 9/22/2022, R1 is able to bathe/dress and feed self and is able to transfer to and from bed. Resident assessment dated 10/6/2022 indicates R1 ambulates independently with or without assistive device. S2 states R1 ambulates independently. In a previous interview conducted with Memory Care Director, Director states R1 ambulates independently. No deficiency was noted during the visit. A copy of this report was provided to Roby.

Licensing Program Analyst (LPA) Luisa Fontanilla conducted a case management visit in connection with complaint 15-AS-20220526161218. During the course of investigation, it was observed that the elopement incident that happened on May 23, 2022 when a resident in the Memory Care Unit wandered out of the facility was not reported to CCL. Deficiency is cited per Title 22 California Code of Regulations Sec 87211(refer to Lic 809D). Exit interview was conducted with Director and Appeal Rights was provided.

During the course of investigation, based on staff interview the facility’s response time to call lights is between 5-10 minutes, if there are multiple calls during the same time, the staff will communicate with each other to check each resident. However, records review revealed that between May 1, 2022 – May 30, 2022, there were at least nine calls from R1 & R2 that staff responded for 30 minutes or more. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties . Exit interview conducted. Appeal Rights and a copy of this report provided to Executive Director.. 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 reviewed staff schedule for the facility, facility has Med Tech, caregivers and management support available on schedule. Facility had sufficient staffing for all three (3) shifts. Residents were observed calm and comfortable in their surroundings. LPA conducted interview with residents and residents reported that they are happy living at the facility and had no issues around staff availability to meet their needs. Residents that were interviewed reported that facility staff attend to their needs. Allegation: Resident's room was not maintained at a comfortable temperature. Based on LPA’s observation, the residents’ apartments temperature was raging from 70-78 degrees Fahrenheit. Based on interview with staff and residents, the residents can control their own thermostat according to what their preference and if a resident needs help on changing the room temperature the residents can call staff or the facility’s maintenance manager. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED . Exit interview conducted and a copy of this report provided to Executive Director.

On this day, February 13, 2023, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a health and safety inspection as a result of the Department receiving a priority 1 complaint (Complaint # 15-AS-20230209091605). LPA met with Business Office Manager Robert 'Rob' Roby, and informed the reason for visit. LPA also met with Resident Services Director Shanina Mason LPA toured the facility including but not limited to common areas, dining rooms, kitchen, medication rooms, activity rooms/areas, and shared bathrooms and common bathrooms on the first and second floors. LPA observed the medication rooms open and attended by med-techs. LPA observed the storage in Memory Care Unit and the salon in Assisted Living Unit locked. LPA randomly selected for inspection a total of 5 resident rooms on the first and second floors. LPA tested the water temperature in 2 of the bathrooms on the first floor. LPA observed the following: 1. Hot water temperature at 80 degrees Fahrenheit. 2. Unlocked Tylenol and Clobetasol cream in resident's (R1) room. Review of LIC602A Physician's Report showed R1 can not store and administer own prescription, non-prescription and PRN medications. Deficiencies are cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of corrections by plan of correction due dates, and any repeat violation within 12 month period may result in civil penalties. Deficiencies and plan and proof of corrections were discussed. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.

On 12/08/22 at 12PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced case management visit to follow up on the criminal record exemption status on staff (S1). LPA explained the purpose of the visit with administrator (ADM). ADM stated that S1 has been terminated since 08/29/22 and no longer works at the facility. Review of Guardian Portal on 12/08/22 shows S1 was associated on 02/22/22 with the facility and still an active employee with no separation or disassociation date. LPA obtained a copy of S1's separation form from ADM dated 08/29/22. Immediate civil penalty of $500 assessed during visit for employment of a non-cleared/excluded individual. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties . Exit interview conducted. Appeal Rights and a copy of this report provided.

It was alleged resident was left in wet diapers for extended periods of time and staff failed to meet resident's hygiene needs . However, based on interview with 3 of 5 staff, R1's hospice agency conducts visit daily and assist R1 with toileting and dressing. S4 and S5 stated that two rounds are conducted per shift. LPA discovered during an interview with S4 and S5 that residents who are under hospice are also changed as needed by caregivers. It was alleged resident was not adequately fed while in care. On 1/16/2023, LPA L. Fontanilla reviewed R1’s hospice notes from April 2021 to August 2021. Based on records reviewed, R1 had a fair appetite. R1 preferred to pick own food and refused assistance from staff with meals. Notes also indicate that R1 was consuming 30-50% 3 times a day. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED . Exit interview conducted and a copy of this report provided to Assistant Executive Director. 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 It was alleged staff failed to administer resident’s medication as prescribed . On 01/25/2023, LPA L. Fontanilla obtained and reviewed R1’s Medication Administration Record (MAR) for 2019-2020 and Centrally Stored Medication and Destruction Record (CSMDR). R1 had an order for Donepezil (Aricept) 10 mg 1 tablet by mouth daily in the morning and ½ tablet (25mg) by mouth after lunch. A review of R1’s MAR for 5/23/2021-6/22/2021 shows an encircled initial of the staff person giving medication from 5/30/2021 till 6/22/2021. Upon verification made by LPA L. Fontanilla with Robert Roby, the code facility uses if a resident refuses to take medication is the staff person’s initial with a circle around it. Based on records reviewed, R1 did not get Donepezil from 5/20/2021-6/22/2021. Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted. Appeal Rights and a copy of this report provided to Assistant Executive Director.

On May 4, 2023 at approximately 11:25 am, Licensing Program Analyst (LPA) Luisa Fontanilla conducted an unannounced Case Management visit. LPA met with Robert Roby and explained the purpose of the visit. On August 30, 2017, the Department concluded a complaint investigation on a substantiated allegation that the facility did not seek timely medical attention resulting in amputation of a resident’s (R1) right pinky toe . The licensee was cited for violating California Code of Regulations (CCR) Title 22, § 87465(a)(1) – Incidental Medical and Dental Care. The facility failed to seek timely medical attention for R1’s toe condition which resulted in amputation. Failing to seek timely medical attention posed an immediate health and safety risk to R1. R1 was taken to the hospital and was diagnosed with gangrene of the toe with cellulitis of the foot. According to the Mayo Clinic, “gangrene refers to the death of body tissue due to either a lack of blood flow or a serious bacterial infection. Gangrene commonly affects the extremities, including your toes, fingers, and limbs, but it can also occur in your muscles and internal organs. Your chances of developing gangrene are higher if you an underlying condition that can damage your blood vessels and affect blood flow, such as diabetes or hardened arteries (atherosclerosis).” ***continuation on Lic 809C*** 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 investigation revealed that on January 11, 2017 and January 12, 2017, R1’s Primary Care Physician ordered the referral for the resident to be brought to a general acute care hospital – wound clinic to be seen. On January 12, 2017, a referral was also issued to have a doctor from the home health care agency come to examine R1’s foot. Facility staff did not follow up with the home health agency to see when the doctor would come to examine R1, and facility staff did not take R1 to the hospital when they noticed the wound was getting worse. On January 19, 2017, R1 was transported by the facility and admitted to the emergency room at the general acute care hospital. According to medical records, when R1 was admitted to the emergency room, R1’s right pinky toe was found to be “necrotic” and “nearly off of foot.” R1 was diagnosed with gangrene of the right pinky toe. According to the Mayo Clinic, “Gangrene is a dangerous and potentially fatal condition. Treatments for gangrene include surgery to remove dead tissue.” The hospital noted that the wound on R1’s right foot was getting worse, the toe was black, foul smelling, and swelling to the foot with redness up to the calf. On January 23, 2017, R1 underwent amputation of the right pinky toe. On January 24, 2017, pathology findings of the amputated right fifth toe, revealed early acute osteomyelitis. According to Mayo Clinic, osteomyelitis is an infection in a bone…infections can reach a bone by traveling through the bloodstream, spread from nearby tissue, or start in the bone itself if an injury exposes the bone to germs. On January 27, 2017, R1 was discharged from the hospital to a skilled nursing facility. A Physician’s Report, dated October 20, 2014, indicates that R1 had no history of a skin condition prior to being admitted to the licensee’s care. ***continuation on Lic 809C*** 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, record review and observation, the facility staff failed to obtain timely medical attention for R1. The licensee’s failure to seek timely care caused R1 to suffer serious bodily injury which required hospitalization and surgery to amputate the right pinky toe. At the time of the complaint visit, an immediate civil penalty of $500 was issued. The licensee was informed that an additional civil penalty is still being determined and might be assessed based on Health and Safety Code § 1569.49. The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. Per Welfare and Institutions Code § 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” Today, May 4, 2023 the Department will be issuing a civil penalty per Health and Safety Code § 1569.49 for a violation that the Department constitutes as serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on August 30, 2017, the amount of the civil penalty today will be $9,500. A copy of the LIC 421D was given to Robert Roby and originals were signed. Exit interview was conducted. Appeal Rights was provided. Robert Roby's signature on this report acknowledges receipt of these rights, found on page 2 of LIC 421D.

Cont from 9099 Based on interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22 is being cited on the attached LIC 9099D. Exit interview was conducted with Administrator and Appeal Rights was provided.

On 05/26/2022, Licensing Program Analyst (LPA) C. Lin conducted an unannounced case management visit regarding self-reporting an AWOL incident in the memory care unit. LPA met with Bernadette Bender Memory Care Director and explained to the purpose of the visit. The Director stated that 4 staff worked on the same PM shift on 5/23/22. The subject resident (R1) was noticed missing in the memory care at around 4:45pm, none of the staff heard the door alarm when R1 eloped, and how R1 eloped was unknown, 911 call was made. The Director confirmed that R1 was able to exit the facility and was found on the street after 2 hours of missing, R1 didn't return to facility after being found. Discharge paperwork was completed by her daughter the next day which was 5/24/22. LPA inspected the memory care unit, there are 5 exit doors around and were observed to be locked during visit. LPA obtained and reviewed R1's physician's report, needs and services plan, admission orders, and staff schedule. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proofs of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties . Exit interview conducted with the Memory Care Director. Appeal Rights and a copy of this report provided.

On 2/17/2022 at 3:00PM, Licensing Program Analysts (LPAs) G. Luk and K. Nguyen arrived unannounced to conduct a case management visit. LPAs met with Administrator, Anoop Nair. While LPAs were conducting a complaint investigation to deliver findings, the following deficiency was observed. During complaint investigation, it was identified that R1 did not have an updated medical assessment on file. R1's medical assessment on file was dated 3/20/2019. Additionally, facility did not submit a death report for resident who expired and was tested positive for COVID-19. During the facility's outbreak, staff did not report positive cases to CCLD per reporting guidelines outlined in Title 22. The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights were provided.

On 04/28/2022, Licensing Program Analyst (LPA) C. Fowler conducted a case management and met with Bernadette Bender Memory Care Director. LPA explained to Bernadette purpose of the visit. During the course of investigation for different issues, a concern regarding Resident 2 (R2) not getting assistance with brushing teeth was addressed. LPA L. Fontanilla reviewed R2’s Physician’s Report dated 3/26/2019 and Appraisal Needs and Services Plan (ANS). Documents reviewed indicate R2 is independent with ADLs and is capable for self-care. On 2/5/2021, R2’s ANS was updated and added partial assist with hygiene/oral care, evacuation, elopement and confusion and reminders for activities. On 3/24/2022, LPA L. Fontanilla interviewed 4 caregivers who have been working at the facility for 2-7 years and have worked with R2. All caregivers interviewed state that R2 is ambulatory and independent with ADLs. Staff told LPA that R2 needed cueing or reminders only with ADLs such as brushing teeth and changing clothes. Staff would hand R2 toothbrush/toothbrush but would not allow staff to brush R2’s teeth. There is no deficiency noted for this visit.