Deer Ridge Memory Care Community.

Residential Care Services Investigation Summary Report Provider/Facility: Deer Ridge Memory Care Provider Type: Assisted Living Facility Community License/Cert.#: 2578 Intake ID: 200607 Compliance Determination #: 69363 Region/Unit #: RCS Region 3 / Unit D Investigator: Carol Gijima Investigation Date(s): 12/01/2025 through 01/07/2026 Complainant Contact Date(s): Allegation(s): 1. Resident to resident incident Investigation Methods: Sample: Total residents: 51 Resident sample size: 3 Closed records sample size: 1 Observations: General environment Residents in their rooms and common areas Staff-to-resident interactions Resident behaviors Interviews: Residents, including the named resident Staff Resident Representative Record Reviews: Resident Characteristic Roster Resident assessments and negotiated service agreements including the records of the named resident Staff progress notes Incident log / reports Investigation Summary: 1. Per observation, record review and interviews with collateral contacts and staff, the facility failed to investigate a resident-to-resident incident to determine the circumstances of the incident and implement interventions to prevent recurrence. The ALF demonstrated failed provider practice as documented in a Statement of Deficiencies dated 01/07/2026. Citation issued. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written This document was prepared by Residential Care Services for the Locator website. N/A 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 Home and Community Living Administration PO Box 45600, Olympia, WA 98504-5600 July 15, 2025 ELECTRONIC-FACSIMILE Administrator Deer Ridge Memory Care Community 3901 5th St SE Puyallup, WA 98374 Assisted Living Facility License # 2578 Licensee: Puyallup Memory Care LLC IMPOSITION OF CIVIL FINE Dear Administrator: On July 7, 2025, 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 Deer Ridge Memory Care Community, located at 3901 5th St SE, Puyallup, 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 July 7, 2025. Civil Fine WAC 388-112A-0611 (1)(a)(i) Who in an assisted 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 388-78A-2474 (2)(e) Training and home care aide certification $400.00 requirements. The licensee failed to ensure four staff completed 12 hours of continuing education (CE) hours as required. This failure to ensure staff were current with continuing education requirements placed all 46 residents at risk from receiving care from an unqualified caregiver. This is an uncorrected deficiency previously cited on March 17, 2025. Administrator Deer Ridge Memory Care Community License #2578 July 15, 2025 Page 2 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: Manfay Chan, Field Manager Region 3, Unit D 9501 Lakewood Dr SW Suite E Lakewood, WA 98499 Phone: (253) 442-3013/ Fax: (253) 589-7240 rcsregion3email@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. Please email your request(s) and supporting documentation to: Administrator Deer Ridge Memory Care Community License #2578 July 15, 2025 Page 3 RCSIDR@dshs.wa.gov OR FAX to: 360-725-3225 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 Deer Ridge Memory Care Community License #2578 July 15, 2025 Page 4 NOTICE: State and federal law provide protections to defendants who are in military service, and to their dependents. Dependents of a service member are the service member’s spouse, the service member’s minor child, or and individual for whom the service member provided more than one-half of the individual’s support for one hundred eight days immediately preceding an application for relief. One protection provided is the protection against the entry of a default judgment in certain circumstances. This notice pertains only to a defendant who is a dependent of a member of the National Guard or a military reserve component under a call to active service, or a National Guard member under a call to service authorized by the governor of the state of Washington, for a period of more than thirty consecutive days. Other defendants in military service also have protections against default judgments not covered by this notice. If you are the dependent of a member of the national guard or a military reserve component under a call to active service, or a national guard member under a call to service authorized by the governor of the state of Washington, for a period of more than thirty consecutive days, you should notify the Department in writing of your status as such within twenty days of the receipt of this notice. If you fail to do so, then a court or an administrative tribunal may presume that you are not a dependent of an active duty member of the national guard or reserves, or a national guard member under a call to service authorized by the governor of the state of Washington, and proceed with the entry of an order of default and/or a default judgment without further proof of your status. Your response to the Department about your status does not constitute an appearance for jurisdictional purposes in any pending litigation nor a waiver of your rights. If you have any questions, please contact Manfay Chan, Field Manager, at (253) 442-3013. Sincerely, Matt Hauser Compliance Specialist Residential Care Services Enclosure cc: Field Manager, Region 3, Unit D RCS Regional Administrator, Region 3 HCS Regional Administrator, Region 3 DDA Regional Administrator, Region 3 WA LTC Ombuds Office of Financial Recovery, Vendor Program Unit HQ Central Files DRW SN

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES Health and Community Living Administration PO Box 45600, Olympia, WA 98504-5600 July 2, 2025 ELECTRONIC-FACSIMILE Administrator Deer Ridge Memory Care Community 3901 5th St SE Puyallup, WA 98374 Assisted Living Facility License # 2578 Licensee: Puyallup Memory Care LLC IMPOSITION OF CIVIL FINE Dear Administrator: On June 18, 2025, the Department of Social and Health Services (DSHS), Residential Care Services completed a Complaint Investigation at your facility. This letter constitutes formal notice of a civil fine on the license for your assisted living facility, also known as Deer Ridge Memory Care Community, located at 3901 5th St SE, Puyallup, 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 June 18, 2025. Civil Fine WAC 388-78A-2371 (1)(2)(3)(4) Investigations. $1,500.00 The licensee failed to conduct investigations to determine the circumstances of the accidents and incidents, implement interventions to prevent recurrence, and to protect residents for five residents. These failures resulted in these residents being placed at risk from continued accidents and incidents without measures to prevent future incidents. This is a recurring deficiency previously cited on May 19, 2023, October 5, 2022, and September 9, 2022. NOTE: This is the violation, which resulted in the fine; see the attached Statement of Deficiencies for any additional violations. Administrator Deer Ridge Memory Care Community License # 2578 July 2, 2025 Page 2 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: Manfay Chan, Field Manager Region 3, Unit D 9501 Lakewood Dr SW Suite E Lakewood, WA 98499 Phone: (253) 442-3013/ Fax: (253) 589-7240 rcsregion3email@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. Please email your request(s) and supporting documentation to: RCSIDR@dshs.wa.gov OR FAX to: 360-725-3225 Administrator Deer Ridge Memory Care Community License # 2578 July 2, 2025 Page 3 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 $1,500.00 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 Deer Ridge Memory Care Community License # 2578 July 2, 2025 Page 4 NOTICE: State and federal law provide protections to defendants who are in military service, and to their dependents. Dependents of a service member are the service member’s spouse, the service member’s minor child, or and individual for whom the service member provided more than one-half of the individual’s support for one hundred eight days immediately preceding an application for relief. One protection provided is the protection against the entry of a default judgment in certain circumstances. This notice pertains only to a defendant who is a dependent of a member of the National Guard or a military reserve component under a call to active service, or a National Guard member under a call to service authorized by the governor of the state of Washington, for a period of more than thirty consecutive days. Other defendants in military service also have protections against default judgments not covered by this notice. If you are the dependent of a member of the national guard or a military reserve component under a call to active service, or a national guard member under a call to service authorized by the governor of the state of Washington, for a period of more than thirty consecutive days, you should notify the Department in writing of your status as such within twenty days of the receipt of this notice. If you fail to do so, then a court or an administrative tribunal may presume that you are not a dependent of an active duty member of the national guard or reserves, or a national guard member under a call to service authorized by the governor of the state of Washington, and proceed with the entry of an order of default and/or a default judgment without further proof of your status. Your response to the Department about your status does not constitute an appearance for jurisdictional purposes in any pending litigation nor a waiver of your rights. If you have any questions, please contact Manfay Chan, Field Manager, at (253) 442-3013. Sincerely, Matt Hauser Compliance Specialist Residential Care Services Enclosure cc: Field Manager, Region 3, Unit D RCS Regional Administrator, Region 3 HCS Regional Administrator, Region 3 DDA Regional Administrator, Region 3 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 PO Box 45600, Olympia, WA 98504-5600 February 15, 2024 ELECTRONIC-FACSIMILE Administrator Deer Ridge Memory Care Community 3901 5th St SE Puyallup, WA 98374 Assisted Living Facility License #2578 Licensee: Puyallup Memory Care LLC IMPOSITION OF CIVIL FINES Dear Administrator: On February 6, 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 civil fines on the license for your assisted living facility, also known as Deer Ridge Memory Care Community, located at 3901 5th St SE, Puyallup, 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 fines on the license are based on the following violation of the RCW and/or WAC as described in the attached Statement of Deficiencies (SOD) report dated February 6, 2024. Civil Fines WAC 388-78A-2160 Implementation of negotiated service agreement. $1,000.00 The licensee failed to ensure that residents received care and services as agreed upon in the negotiated service agreement (NSA) for six residents. This failure placed all six residents at risks for developing wounds, infections, and decreased skin integrity. This is a recurring deficiency on May 4, 2023, and an uncorrected deficiency previously cited on November 21, 2023. Administrator Deer Ridge Memory Care Community License #2578 February 15, 2024 Page 2 RCW 70.129.140 (1) Quality of life -- Rights. $1,000.00 WAC 388-78A-2660 (2) Resident rights. The licensee failed to ensure that residents received care and services in a manner that enhances their dignity and quality of life for seven residents. This failure resulted in seven residents not receiving showers which placed them at risk for developing wounds, infections and a decreased in dignity and quality of life. This is a recurring deficiency on May 4, 2023, and an uncorrected deficiency previously cited on November 21, 2023. NOTE: These are the violations, which resulted in the fines; 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: Manfay Chan, Field Manager Region 3, Unit D 9501 Lakewood Dr SW Suite E Lakewood, WA 98499 Phone: (253) 442-3013/ Fax: (253) 589-7240 rcsregion3email@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). Administrator Deer Ridge Memory Care Community License #2578 February 15, 2024 Page 3 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. 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 fines by requesting a formal administrative hearing to challenge the deficiency, which resulted in the civil fines. 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 fines are due to the Office of Financial Recovery twenty-eight (28) calendar days after receipt of this letter. Mail a check for $2,000.00 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, Washington 98507-9501 1-800-562-6114 (extension 45919) OFRMMISVendor@dshs.wa.gov Administrator Deer Ridge Memory Care Community License #2578 February 15, 2024 Page 4 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. If you have any questions, please contact Manfay Chan, Field Manager, at (253) 442-3013. Sincerely, Matt Hauser Compliance Specialist Residential Care Services Enclosure cc: Field Manager, Region 3, Unit D RCS Regional Administrator, Region 3 HCS Regional Administrator, Region 3 DDA Regional Administrator, Region 3 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 PO Box 45600, Olympia, WA 98504-5600 June 5, 2024 ELECTRONIC-FACSIMILE Administrator Deer Ridge Memory Care Community 3901 5th St SE Puyallup, WA 98374 Assisted Living Facility License # 2578 Licensee: Puyallup Memory Care LLC IMPOSITION OF CIVIL FINE Dear Administrator: On May 24, 2024, the Department of Social and Health Services (DSHS), Residential Care Services completed a Complaint Investigation at your facility. This letter constitutes formal notice of a civil fine on the license for your assisted living facility, also known as Deer Ridge Memory Care Community, located at 3901 5th St SE, Puyallup, 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 May 24, 2024. Civil Fine WAC 388-78A-2371(1)(2)(3) Investigations. $1,500.00 The licensee failed to conduct an investigation that determined the circumstances of the events and institute measures to prevent future incidents when residents sustained falls and injuries of unknown source for three residents. This failure contributed to one resident sustaining two falls with fractures, requiring surgery and hospitalization, another resident not having preventative measure in place, and the third resident at risk for abuse and continued harm. This is a recurring deficiency previously cited on May 19, 2023, October 5, 2022, September 9, 2022, and June 23, 2022. Administrator Deer Ridge Memory Care Community License # 2578 June 5, 2024 Page 2 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: Manfay Chan, Field Manager Region 3, Unit D 9501 Lakewood Dr SW Suite E Lakewood, WA 98499 Phone: (253) 442-3013/ Fax: (253) 589-7240 rcsregion3email@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. Send your written request to: Informal Dispute Resolution Program Manager Residential Care Services PO Box 45600 Olympia, Washington 98504-5600 Administrator Deer Ridge Memory Care Community License # 2578 June 5, 2024 Page 3 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 $1,500.00 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 Deer Ridge Memory Care Community License # 2578 June 5, 2024 Page 4 If you have any questions, please contact Manfay Chan, Field Manager, at (253) 442-3013. Sincerely, For: Matt Hauser Compliance Specialist Residential Care Services Enclosure cc: Field Manager, Region 3, Unit D RCS Regional Administrator, Region 3 HCS Regional Administrator, Region 3 DDA Regional Administrator, Region 3 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 PO Box 45600, Olympia, WA 98504-5600 August 24, 2023 ELECTRONIC-FACSIMILE (Amended Statement of Deficiencies Dated May 19, 2023) (Amendments are in Bold Underlined Italic) Administrator Deer Ridge Memory Care Community 3901 5th St SE Puyallup, WA 98374 Assisted Living Facility License #2578 Licensee: Puyallup Memory Care LLC AMENDED STATEMENT OF DEFICIENCIES IMPOSITION OF CIVIL FINE Dear Administrator: On May 19, 2023, the Department of Social and Health Services (DSHS), Residential Care Services completed a Complaint Investigation at your facility. This letter constitutes formal notice of a civil fine on the license for your assisted living facility, also known as Deer Ridge Memory Care Community, located at 3901 5th St SE, Puyallup, 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 May 19, 2023, and amended on August 24, 2023. This amendment is for the Statement of Deficiencies only. The Civil Fine enforcement action remains the same. Civil Fine WAC 388-78A-2371 (1)(2) Investigations. $1,000.00 The licensee failed to investigate circumstances surrounding a resident’s falls with one fall resulting in a left clavicle fracture (a break in the collar bone) for one resident. This failure contributed to the residents having recurring falls, hospitalization, pain, and a decrease in quality of life. This is a recurring deficiency previously cited on October 5, 2022, September 9, 2022, and June 23, 2022. Administrator Deer Ridge Memory Care Community License #2578 August 24, 2023 Page 2 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: Manfay Chan, Field Manager Region 3, Unit D 9501 Lakewood Dr SW Suite E Lakewood, WA 98499 Phone: (253) 442-3013/ Fax: (253) 589-7240 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. Send your written request to: Informal Dispute Resolution Program Manager Residential Care Services PO Box 45600 Olympia, Washington 98504-5600 Administrator Deer Ridge Memory Care Community License #2578 August 24, 2023 Page 3 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 $1,000.00 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, Washington 98507-9501 1-800-562-6114 (extension 45919) 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 Deer Ridge Memory Care Community License #2578 August 24, 2023 Page 4 If you have any questions, please contact Manfay Chan, Field Manager, at (253) 442-3013. Sincerely, Matt Hauser Compliance Specialist Residential Care Services Enclosure cc: Field Manager, Region 3, Unit D RCS Regional Administrator, Region 3 HCS Regional Administrator, Region 3 DDA Regional Administrator, Region 3 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 PO Box 45600, Olympia, WA 98504-5600 December 5, 2023 ELECTRONIC-FACSIMILE Administrator Deer Ridge Memory Care Community 3901 5th St SE Puyallup, WA 98374 Assisted Living Facility License #2578 Licensee: Puyallup Memory Care LLC IMPOSITION OF CIVIL FINES Dear Administrator: On November 21, 2023, 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 civil fines on the license for your assisted living facility, also known as Deer Ridge Memory Care Community, located at 3901 5th St SE, Puyallup, 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 fines on the license are based on the following violation of the RCW and/or WAC as described in the attached Statement of Deficiencies (SOD) report dated November 21, 2023. Civil Fines WAC 388-78A-2160 Implementation of negotiated service agreement. $600.00 The licensee failed to provide showers for ten residents. This failure resulted in all ten residents not receiving showers as agreed upon which contributed to risk of skin infections and decreased skin integrity. This is an uncorrected deficiency previously cited on May 4, 2023. Administrator Deer Ridge Memory Care Community License #2578 December 5, 2023 Page 2 WAC 388-78A-2660(2) Resident rights. $600.00 The licensee failed to ensure that residents received care and services in a manner that enhances their dignity and quality of life for ten residents. This failure resulted in all ten residents not receiving care and services which contributed to the decrease in dignity and quality of life. This is an uncorrected deficiency previously cited on May 4, 2023. NOTE: These are the violations, which resulted in the fines; 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: Manfay Chan, Field Manager Region 3, Unit D 9501 Lakewood Dr SW Suite E Lakewood, WA 98499 Phone: (253) 442-3013/ Fax: (253) 589-7240 rcsregion3email@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). Administrator Deer Ridge Memory Care Community License #2578 December 5, 2023 Page 3 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. 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 fines by requesting a formal administrative hearing to challenge the deficiency, which resulted in the civil fines. 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 fines are due to the Office of Financial Recovery twenty-eight (28) calendar days after receipt of this letter. Mail a check for $1,200.00 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, Washington 98507-9501 1-800-562-6114 (extension 45919) OFRMMISVendor@dshs.wa.gov Administrator Deer Ridge Memory Care Community License #2578 December 5, 2023 Page 4 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. If you have any questions, please contact Manfay Chan, Field Manager, at (253) 442-3013. Sincerely, Matt Hauser Compliance Specialist Residential Care Services Enclosure cc: Field Manager, Region 3, Unit D RCS Regional Administrator, Region 3 HCS Regional Administrator, Region 3 DDA Regional Administrator, Region 3 WA LTC Ombuds Office of Financial Recovery, Vendor Program Unit HQ Central Files DRW HP