Pacifica Senior Living Union City.

Report Continue LIC 9099… It was alleged that staff failed to provide proper care and supervision to a resident having suicidal ideation. LPA reviewed a sample of eight (8) resident files and gathered various documents, including but not limited to: the staff roster with contact information, resident roster, resident admission agreements, physician reports, care plans, narrative charting, progress notes, and communication log. In addition, the LPA interviewed the Executive Director (ED), seven (7) staff members, and eight (8) residents. All seven staff members stated that if a resident expresses any suicidal ideation, they are trained to ask leading questions, help redirect the resident to understand their thoughts better, and immediately report the situation to the ED or director, who would then contact the Union City Police Department. All eight (8) residents interviewed stated that staff provides appropriate care and supervision whenever residents express—or if they were ever to express—suicidal ideation to staff or anyone else. One resident (R1) clarified, “I do not have any suicidal ideation thoughts. I called the crisis team to talk, but I never mentioned that. I am mad that people keep on asking.” R1 stated, “staff do their round check and check in with me every hour”. Report Continue on LIC 9099c1... 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 continue on LIC 9099c1... Allegation: Staff failed to accord privacy to the residents in care- unsubstantiated During the investigation, the Licensing Program Analyst (LPA) conducted interviews with the Executive Director (ED), six (6) staff members, and eight (8) residents. The investigation focused on the allegation that staff failed to respect residents’ privacy or provide adequate privacy for them. The LPA also reviewed relevant facility documents, including staff schedules, resident records, care plans, and policy and procedure manuals regarding resident privacy. During interviews, all eight residents stated that staff consistently provide privacy during personal care activities, such as bathing, dressing, and medical treatment. Several residents mentioned that staff always knock before entering their rooms and ensure doors and curtains are closed when privacy is needed. Residents also reported that staff respect their privacy when they are talking on the phone, ensuring conversations remain private and uninterrupted. No residents interviewed reported concerns about their privacy or described any incidents in which privacy was not respected. R1 stated, “They give me privacy, staff are always there in the med room”. Both staff and residents consistently reported that privacy is maintained during care. Based on the preponderance of evidence, the allegations are unsubstantiated. No deficiencies were cited regarding this allegation. An exit interview is conducted, and a copy of this report is provided.

Report Continue… LPA reviewed a sample of six (6) resident files and collected documents including, but not limited to, the staff roster with contact information, resident roster, resident admission agreements, physician reports, care plans, end-of-shift notes, and the facility activity calendar. Additionally, LPA toured the facility including but not limited to the assisted living, memory care unit, activity room and common areas. During the visit, LPA observed that both the assisted living unit and memory care unit were actively engaged in scheduled activities. LPA interviewed six (6) staff and fifteen (15) residents. Staff reported that residents are informed of scheduled activities, encouraged to participate, and offered assistance as needed; however, participation is voluntary and based on individual resident preference. Residents provided mixed responses. Some residents reported that they are aware of and participate in activities offered at the facility and expressed satisfaction with the variety and frequency. Other residents indicated that they choose not to participate or prefer to engage in independent activities such as watching television, reading, or resting in their rooms. No residents reported being prevented from participating in activities or stated that staff refused to provide access to activities. Additionally, LPA interviewed Resident 1 (R1), who was observed smiling, moving R1 head, and appearing to enjoy music during the visit. When asked whether staff check in and inform R1 about activities, R1 responded “yes.” R1 also confirmed that staff offer to engage in activities, inform R1 about scheduled activities, and that R1 enjoys listening to music. In addition, LPA reviewed the facility’s activity schedule and observed posted activity calendars in common areas. Documentation reviewed supports the idea that activities are planned and made available to residents on a regular basis. Although some residents expressed personal preferences not to participate, there is insufficient evidence to support the claim that staff failed to ensure activities were provided. Therefore, the allegation is unsubstantiated at this time.

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 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.

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.

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.

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.

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.

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 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.