Aegis Living Bellevue Overlake.

This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2567 Compliance Determination # 69728 Plan of Correction Aegis Living Bellevue Overlake Completion Date Page 4 of 8 Licensee: Aegis Senior Communities LLC 12/18/2025 Plan/Attestation Statement I hereby certify that I have reviewed this report and have taken or will take active measures to correct this deficiency. By taking this action, Aegis Living Bellevue Overlake is or will be in compliance with this law and / or regulation on (Date)________________ . In addition, I will implement a system to monitor and ensure continued compliance with this requirement. Administrator (or Representative) Date WAC 388-78A-2100 Ongoing assessments. (2) The assisted living facility must: (a) Complete a full assessment addressing the elements set forth in WAC 388-78A-2090 for each resident at least annually; (b) Complete an assessment specifically focused on a resident's identified problems and related issues: (i) Consistent with the resident's change of condition as specified in WAC 388-78A-2120 ; This requirement was not met as evidenced by: Based on observation, interview, and record review, the facility failed to assess 1 of 3 sampled residents (Resident 5) for their ability to safely use medical devices. This failure placed Resident 5 at risk for possible injury and unmet care needs. Findings included… Note: Washington Administrative Code (WAC) 388-78A-2090, Full assessment topics. The assisted living facility must obtain sufficient information to be able to assess the capabilities, needs, and preferences for each resident, and must complete a full assessment addressing the following, within fourteen days of the resident's move-in date, unless extended by the department for good cause: (6) Significant known behaviors or symptoms of the individual causing concern or requiring special care, including: (e) Other safety considerations that may pose a danger to the individual or others, such as use of medical devices or the individual's ability to smoke unsupervised, if smoking is permitted in the assisted living facility. RESIDENT 5 Observation on 12/10/2025 at 9:50 AM showed two transfer poles (a floor-to-ceiling grab bar that the bottom end of the pole was mounted to the floor and the top end of the This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website.

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES Aging and Long-Term Support Administration PO Box 45600, Olympia, WA 98504-5600 August 13, 2024 ELECTRONIC-FACSIMILE Administrator Aegis Living Bellevue Overlake 1845 116th Ave NE Bellevue, WA 98004 Assisted Living Facility License # 2567 Licensee: Aegis Senior Communities LLC IMPOSITION OF CIVIL FINE Dear Administrator: On August 5, 2024, the Department of Social and Health Services (DSHS), Residential Care Services completed a follow-up visit at your facility. This letter constitutes formal notice of a civil fine on the license for your assisted living facility, also known as Aegis Living Bellevue Overlake, located at 1845 116th Ave NE, Bellevue, by the State of Washington, Department of Social and Health Services. These actions are taken under the authority granted pursuant to Laws of 1998, Chapter 272 and RCW 18.20.190. The civil fine on the license is based on the following violation of the RCW and/or WAC as described in the attached Statement of Deficiencies (SOD) report dated August 5, 2024. Civil Fine WAC 388-112A-0611 (1)(a)(i)(ii)(iii)(iv)(b)(c)(d)(i)(ii)(2) Who in an assisted $400.00 living facility is required to complete continuing education training each year, how many hours of continuing education are required, and when must they be completed? WAC 388-112A-0720 (2)(a) What are the CPR and first-aid training requirements? WAC 388-78A-2474 (2)(d)(e) Training and home care aide certification requirements The licensee failed to ensure that two staff met all their training requirements needed to provide resident care. This failure placed all 108 residents at risk of receiving inadequate care from untrained staff. Administrator Aegis Living Bellevue Overlake License # 2567 August 13, 2024 Page 2 This is an uncorrected deficiency previously cited for WAC 388-78A-2472 subsection (2)(e) and WAC 388-112A-0611 subsection (1)(a)(iii) on June 6, 2024. NOTE: This is the violation, which resulted in the fine; see the attached Statement of Deficiencies for any additional violations. Attestation (Plan of Correction): Return the enclosed SOD within 10 calendar days with the following: • The date you have or will have each deficiency corrected; • A signature and date attesting that you are taking actions to correct and maintain correction for each cited deficiency. Return the signed and dated SOD to: Laurie Anderson, Field Manager Region 2, Unit D 20425 72nd Ave S suite 400 Kent, WA 98032-2388 Phone: (253)234-6020 / Fax: (253) 395-5071 rcsregion2email@dshs.wa.gov Appeal Rights: You have two appeal rights: Informal Dispute Resolution (IDR) and an Administrative Hearing. Each has a different request timeline. Informal Dispute Resolution [RCW 18.20.195] You have an opportunity to challenge the deficiencies and/or enforcement actions through the state's IDR process. All IDR requests must be in writing and include: • The deficiencies you are disputing; and • The method of review you prefer (face-to-face, telephone conference or documentation review). The written request must be received by the 10th working day from receipt of this letter. During the IDR process, you will have the opportunity to present written and/or oral evidence to dispute the deficiencies. Administrator Aegis Living Bellevue Overlake License # 2567 August 13, 2024 Page 3 Send your written request to: Informal Dispute Resolution Program Manager Residential Care Services PO Box 45600 Olympia, Washington 98504-5600 Formal Administrative Hearing You may contest the civil fine by requesting a formal administrative hearing to challenge the deficiency, which resulted in the civil fine. All hearing requests must be in writing and include: • A copy of this letter; and • A copy of the Statement of Deficiencies. The written request must be received within twenty-eight (28) calendar days of receipt of this letter. Send your written request to: Office of Administrative Hearings PO Box 42489 Olympia, Washington 98504-2489 Payment: If you do not request a formal administrative hearing, the civil fine is due to the Office of Financial Recovery twenty-eight (28) calendar days after receipt of this letter. Mail a check for $400.00 payable to the ‘Department of Social and Health Services’, and if you have or have had a Medicaid resident(s), please include your ProviderOne ID Number # on the check, to: DSHS Office of Financial Recovery PO Box 9501 Olympia, WA 98507-9501 (360) 664-5919 / FAX: (360) 664-8401 OFRMMISVendor@dshs.wa.gov If the Office of Financial Recovery has not received your payment within twenty-eight (28) days after receipt of this letter, interest will begin to accrue immediately on the balance, at the rate of one percent per month. If you do not submit a hearing request or make payment within twenty-eight (28) days, the balance due will be recovered. Administrator Aegis Living Bellevue Overlake License # 2567 August 13, 2024 Page 4 If you have any questions, please contact Laurie Anderson, Field Manager, at (253) 234-6020. Sincerely, Matt Hauser Compliance Specialist Residential Care Services Enclosure cc: Field Manager, Region 2, Unit D RCS Regional Administrator, Region 2 HCS Regional Administrator, Region 2 DDA Regional Administrator, Region 2 WA LTC Ombuds Office of Financial Recovery, Vendor Program Unit HQ Central Files DRW HP

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 20425 72nd Avenue S, Suite 400, Kent, WA 98032 Aegis Senior Communities LLC Aegis Living Bellevue Overlake 1845 116th Ave NE Bellevue, WA 98004 RE: Aegis Living Bellevue Overlake License # 2567 Dear Administrator: This letter addresses Compliance Determination(s) 28131 (Completion Date 08/15/2023) and 25055 (Completion Date 06/09/2023). The Department completed a follow-up inspection of your Assisted Living Facility on 08/15/2023 and found no deficiencies. Your facility meets the Assisted Living Facility licensing requirements. The Department found that deficiencies for the following licensing laws and regulations were corrected: WAC 388-78A-2466-1-a, WAC 388-78A-2466-1-b, WAC 388-78A-2466-1 The Department staff who did the on-site verification: Michelle Yip, ALF Licensor If you have any questions, please contact me at (253)234-6020. Sincerely, Laurie Anderson, Field Manager Region 2, Unit D Residential Care Services This document was prepared by Residential Care Services for the Locator website. Residential Care Services Investigation Summary Report Provider/Facility: Aegis Living Bellevue Provider Type: Assisted Living Facility Overlake License/Cert.#: 2567 Intake ID: 84961 Compliance Determination #: 25055 Region/Unit #: RCS Region 2 / Unit D Investigator: Michelle Yip Investigation Date(s): 06/08/2023 through 06/09/2023 Complainant Contact Date(s): Allegation(s): Expired staff background check Investigation Methods: Sample: Total residents: 102 Resident sample size: 0 Closed records sample size: 0 Observations: Facility's common area Interviews: Administrator Record Reviews: Staff personnel file, Washington State Name and Date of Birth Background Check (BGI) Investigation Summary: Review of the facility's personnel file for one sampled care staff showed that the staff's initial BGI was completed on 04/23/2021 and expired on 04/23/2023. The facility stated that they were unaware the staff's BGI expired. The facility immediately responded and completed the BGI while Licensor was onsite on 06/08/2023, 46 days overdue. The facility stated that the staff worked in the facility with no valid BGI between 04/23/2023 and 06/08/2023. Review of the staff's updated BGI showed results that no background information was reported. Violation was identified. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A This document was prepared by Residential Care Services for the Locator website. Residential Care Services Investigation Summary Report Provider/Facility: Aegis Living Bellevue Provider Type: Assisted Living Facility Overlake License/Cert.#: 2567 Intake ID: 85345 Compliance Determination #: 25055 Region/Unit #: RCS Region 2 / Unit D Investigator: Michelle Yip Investigation Date(s): 06/08/2023 through 06/09/2023 Complainant Contact Date(s): Allegation(s): Expired staff background check Investigation Methods: Sample: Total residents: 102 Resident sample size: 0 Closed records sample size: 0 Observations: Facility's common area Interviews: Administrator Record Reviews: Staff personnel file, Washington State Name and Date of Birth Background Check (BGI) Investigation Summary: Review of the facility's personnel file for one sampled care staff showed that the staff's initial BGI was completed on 04/23/2021 and expired on 04/23/2023. The facility stated that they were unaware the staff's BGI expired. The facility immediately responded and completed the BGI while Licensor was onsite on 06/08/2023, 46 days overdue. The facility stated that the staff worked in the facility with no valid BGI between 04/23/2023 and 06/08/2023. Review of the staff's updated BGI showed results that no background information was reported. Violation was identified. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A This document was prepared by Residential Care Services for the Locator website. STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 20425 72nd Avenue S, Suite 400, Kent, WA 98032 Statement of Deficiencies License #: 2567 Compliance Determination # 25055 Plan of Correction Aegis Living Bellevue Overlake Completion Date Page 1 of 3 Licensee: Aegis Senior Communities LLC 06/09/2023 You are required to be in compliance at all times with all licensing laws and regulations to maintain your Assisted Living Facility license. The department completed data collection for an unannounced on-site complaint investigation on 06/08/2023, 06/08/2023, 06/12/2023 and 06/08/2023 of: Aegis Living Bellevue Overlake 1845 116th Ave NE Bellevue, WA 98004 This document references the following complaint number(s): 84961, 85345 The following sample was selected for review during the unannounced on-site visit: 0 of 102 current residents and 0 former residents. The department staff that investigated the Assisted Living Facility: Michelle Yip, ALF Licensor From: DSHS, Aging and Long-Term Support Administration Residential Care Services, Region 2 , Unit D 20425 72nd Avenue S, Suite 400 Kent, WA 98032 As a result of the on-site visit(s), the department found that you are not in compliance with the licensing laws and regulations as stated in the cited deficiencies in the enclosed report. Residential Care Services Date I understand that to maintain an Assisted Living Facility license, the facility must be in compliance with all the licensing laws and regulations at all times. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2567 Compliance Determination # 25055 Plan of Correction Aegis Living Bellevue Overlake Completion Date Page 2 of 3 Licensee: Aegis Senior Communities LLC 06/09/2023 Administrator (or Representative) Date WAC 388-78A-2466 Background checks Washington state name and date of birth background check Valid for two years National fingerprint background check Valid indefinitely. (1) A Washington state name and date of birth background check is valid for two years from the initial date it is conducted. The assisted living facility must ensure: (a) A new DSHS background authorization form is submitted to the department's background check central unit every two years for all administrators, caregivers, staff persons, volunteers and students; and (b) There is a valid Washington state name and date of birth background check for all administrators, caregivers, staff persons, volunteers and students. This requirement was not met as evidenced by: Based on interview and record review, the facility failed to complete a Washington State name and date of birth background check every two years for 1 of 1 sampled staff (Staff A, Lead Medication Care Manager). This failure placed all the residents at risk for potential abuse or neglect by staff with an unknown background. Findings included... Review of the facility's undated "staff roster" showed the facility hired Staff A on 05/04/2021. Review of Staff A's facility personnel records showed that the facility first completed a Washington State Name and Date of Birth Background Inquiry (BGI) on 04/23/2021. The first BGI for Staff A expired on 04/23/2023. Further review of Staff A's records showed that the facility completed a new BGI on 06/08/2023. Staff D's two-year BGI review was 46 days past due. During an interview on 06/08/2023 at noon, Staff B, Senior General Manager, confirmed that they were unaware Staff A's first BGI expired. Staff B stated that they did not complete a new BGI for Staff A when Staff A's BGI expired in April 2023. Staff A stated that on 06/08/2023, they completed Staff A's BGI. During a follow-up interview on 06/09/2023 at 3:23 PM, Staff B stated that the facility hired a new business office manager who started in the position in May 2023. Staff B stated that the business office manager reviewed staff's personnel files and completed staff's background check. Staff B also stated that the facility implemented a new system This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2567 Compliance Determination # 25055 Plan of Correction Aegis Living Bellevue Overlake Completion Date Page 3 of 3 Licensee: Aegis Senior Communities LLC 06/09/2023 that tracked staff's personnel files and prompted when a staff was due for background check. Staff B stated that when they reviewed the staffs' personnel files, they missed Staff A's BGI renewal in April 2023. Plan/Attestation Statement I hereby certify that I have reviewed this report and have taken or will take active measures to correct this deficiency. By taking this action, Aegis Living Bellevue Overlake is or will be in compliance with this law and / or regulation on (Date)________________ . In addition, I will implement a system to monitor and ensure continued compliance with this requirement. Administrator (or Representative) Date This document was prepared by Residential Care Services for the Locator website.