Aegis Living Shoreline.

This document was prepared by Residential Care Services for the Locator website. STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEAL TH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 20311 52nd Ave W, Suite 100, Lynnwood, WA 98036 14900 1st Ave Shoreline LLC Aegis Living Shoreline 14900 1ST AVENUE NE SHORELINE, WA 98155 RE: Aegis Living Shoreline License# 2592 Dear Administrator: This letter addresses Compliance Determination(s) 70695 (Completion Date 12/31/2025) and 67388 (Completion Date 10/30/2025). The Department completed a follow-up inspection of your Assisted Living Facility on 12/31/2025 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-2474-1, WAC 388-78A-2474-2-c, WAC 388-78A-2474-2-d, WAC 388-78A-2474- 2-e, WAC 388-78A-2474-3, WAC 388-78A-2466-1-a The Department staff who did the on-site verification: Alma Duran, Licensor If you have any questions, please contact me at (253)312-1446. Sincerely, . s.· Jamie Singer, Field Man~ Region 2, Unit J Residential Care Services This document was prepared by Residential Care Services for the Locator website. 11.10.2025 12:30:05 State of 1-lashington 3/10 STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGiNG AND LONG-TERM SUPPORT .ADMINISTRATION 20311 52nd Ave Vl': Sl)it~ 1D O, Lynnwood, WA 98036 Statement of Deficiencies License #: 2592 Compliance Determination #67388 Plan o-f Correction Aegis Living Shoreline Completion ·oate Page 1 of 5 Licensee: 149U0 1st Ave Shoreline LLC 10/30/2025 You are ta.quired ·to be in compliance at all times with all licensing laws and regulafams to maintajn yoLir Assisted Living .Facility license .. The department completed data collection for an unannounced on-site follow-up on 10/17/2025 of: • Aegis Living Shoreline 14900 1ST AVENUE NE SHORELINE, WA 98155 This document references the following SOD dated: 10/30/2025 The following sample was $elected for review during the unannounced on-site visit: 2 of 91 current residents and 0 former residents. The department staff that inspected the Assisted Living Facility: Alma Duran, Licensor Keiko Kitano, .Licensor From: DSHS., Aging and Long-Term Support Administration Residential Care Services, Region 2 , Unit J 20311 52nd Ave W, Suite ·t 00 Lynnwood, WA 98036 This document was prepared by Residential Care Services for the Locator website. 11.10.2025 12:30:05 State of J.lashington 4/10 Statement of Detici_e_ncies License #: 2592 Compliance. Determination# 67388 Pl:an of Correction Aegis Living Shore.line Completion Date Page 2 of 5 Licensee: 14900 1st Ave Shore line LLC 10/30i2025 As a result of the on-site visit(s) the department found thatyou are not in compliance with tile licensing laws and regulations as stated in the cited deficiencies in the enclosed report 11/10/2025 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 .air times. I I / I D / ;)vo;is- oate WAC 388-78A-2474 Training and home care aide certification requirements. (1) The assisted living facility must ensure staff persons hired before January 7, 20:12 meet training requirements in effect on the date hired, including requirements in chapter 388-112A WAC. (2) The assiste.d living facility ·must ensure all assisted living facility -administrators, or their designees, and caregivers hired on or after January 7, 2012 meet the long-term care worker tr~ining requirements of chapter 388-112A WAC, including but not limited to: (c) SpecfaHy for dementia, mental illness and/or developmental disabllities when serving residents with any of those primary special needs; (d) C<;irdiopulmon_ary resuscitation and first aid~ a11d (e) Continuing education. (3) The assisted living facility must ensure that all staff receive appropriate training and orientation to perform ttieir specific job duties and responsibilities. this requirement was not met as evidenced by: Based on interview and record review: the Assisted Living Facility (ALF) failed to ensure that 5 of 6 sampled staff members (.Staff A, 8, C, F, and G·) , met the long-term care workers training requirements under Wa$hington Adm:inistrative Code (WAC) 388-112A. This placed 91 residents in the ALF at risk of not receiving proper ·care and services from inadequately trained staff members and potentially compromiseo the residents1 health conditions. Findings in.duded .... This document was prepared by Residential Care Services for the Locator website. 11.10.2025 12:30:05 State of washington 51m Statement of Detici_encies License #: 2592 Compliance Determination # 67388 Plan of Correction Aegis Living Shore.line Completion Date Page 3 of 5 Licensee: 14900 tst Ave Shoreline LLC 10/30i2025 NOTE: Washington Administrative Code (WAC) 388-78A-2500 - Specialrzed tra_rning for _mental illness~. The assisted living facility must ensure completion of specialized training, consistent with chapter 388-112A WAC, to serve rE3sider,ts-with mental .il_ln_ess, whenever at least one of the residents in the assisted Jiving facility has a mental illness that js the resident's primary specjaJ need and is a person who has been diagnosed with or treated for an Axi.s I or Axis II diagnosis; as described in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. NOTE: WAC 388-78A-251 0 - Special.ized training for d-ementia. The assisted living facility must ensure completion of specialized training, consistent with chapter 388-112A WAC, to serve residents with dementia, whenever at least one of the resjdents in the (3Ssisted living facility nas dementia that i's the resident's primary special need and has symptoms consistent with dementia as assessed per WAC 388-78A-2090(7); NOTE:: WAC 388-112A-0495 What are the specialty training and supervision requirements for long teIm care workers in adult family homes, assisted living facilities, and enhanced services facilitres? Assisted living faciiities. (4) If .an assisted living_f acility-serves one or more residenfa With special needs, the assisted living facility must ensure that a long-term care worker employed t>y the facility demonstrates completion of or completes and demonstrate$ competency in specialty tra_ining within 120 day.s of hire. However, if specialty tr.ainin_g is no.t integrated with basic training, the specialty training must be completed within. 90 days of completion of ba·sic training. DEMENTIA AND MENTAL HEALTH SPECIALTY TRAINING Review of the undated Resident Characteristics Roster .(RCR) showedthe ALF had been providing care and services for 91 residents .. The RCR showed s.even residents Were identified with cognitive impairm_entf dementia I Alzheimer's (a group of sym_ptorns that affects mernory, thinking and interferes with daily life), and eight residents with a diagnosis of . Record review showed the ALF hired Staff A (Gare:giVer) on 11/26/2024. Staff A'.s record showed no documentation of completion of the required Dementia and Mental Health {M H) specialty training within 120 days of their employment. CARDIOPULMONARY RESUSCITATION (CPR) AND FIRST AID CARD Review of ~taff records showed thc:it the ALF hired St9ff B (Caregiv~r) on 08/17/2025. R~view of Staff B's record showed no CPR ·and first aid certificates. Review of staff records showed that the ALF hired Staff F (Caregivei) on 05/06/2025. Review of Staff Fs record showed no valid first aid certificates. 12 HOURS CONTINUING EDUCATION This document was prepared by Residential Care Services for the Locator website. 11.10.2025 12:30:05 State of washington 61m State111ent of Deficiencies License #: 2592 Cornp_liance Determination # 67388 Plan of Correction Aegis Living Shore.line Completion Date .Page4 of5 Licensee: 14900 tst Ave Shoreline LLC 10/30i2025 NOTE:: WAC 388-1.12A-0611 Who is an assisted living facility Is required to complete continuing eouc~tion training each. ye~r, how many hours of continqing eoucat:ion are required, and when must they be completed? (1) The continuing education training requirements that apply to certain individuals working in assisted living facilities are described in this section. (a) The following long term care workers must complete 12 hoLirs of continuing education by thek birthday each year: (I) A certified home care aide (HCA); Review of staff records showed thatthe ALF hired Staff C (Caregiver) on 10/01/2023. Review of Staff G's record showed that they had not completed the 12 hours of the co-ntinuirig education (CE) credits between their birthdates of 07/18/2024 and 07/18/2025. Review of staff records showed that the ALF hired Staff G (Caregiver) on 03/29/2022. Review of Staff Gs record showed that they had not completed the 12 hours of the continuing education (CE) credits between their birthdates of 10/16/2024 and 10/16/2025. In an interview~ on 10/17/2025 at 9:50 AM Staff H (Area Business Office Manager) ·acknowledged that Staff A did not complete the required dementia/MH training, there was no CPR/first.aid training for Staff Band Staff F, and Staff G and:Staff G did not complete the 12 hoLirs training between their .birth dates. This is an uncorrected deficiency previously cited on 08/18/2025. Plan/Attestation Statement I hereby certify that I have reviewed this report and have tak_en or will take active measures to correct this deficiency. By taking this action, Aegis Uvinq Shoreline is or Will be in compliance with this law and I or regulation on (Date) l cl. I 14 /_oDQS" In addition, I will fmplement a system to monitor and ensure: continued compliance with this requirement. l 111 ,o &-0as Date WAC 388-78A-2466 Background checks Washington state .name and date Qf birth background check Valid for two years National fingerprint background check Valid indefinitely. This document was prepared by Residential Care Services for the Locator website. 11.10.2025 12:30:05 State of Uclshington 7/10 State111ent of Deficiencies License#: 2592 Compliance Determination # 67388 Plan of Correction Aegis Living Shore.line Completion Date Page 5 of 5 Licensee: 14900 tst Ave Shoreline LLC 10/30i2025 (1) A Washington state name and date of birth background check ts valid for two years from the initial date it is conducted. The assisted living facility must ensure: (a) A new DSHS background authorizati.on form is submitted to the· de·partrne·nt's background check central unit every two years for all administrators, caregivers, staff persons, volunteers and students; and This requfrement was not met as· evidenced by·: Based on interview and record review, the Assisted Living Facility (ALF) failed to ensure the Washington State name and date of birth background inquiry (BGI) for 2 of 3 sampled staff members (Staff D and I) were renewed before the two-year expiration. This placed 9:1 residents at risk of receiving care from staff whose criminal background history was unknown. Findings included ... Review of records for Staff D (Lead Cook), hired on 12/20/2011, showed their BGI expired as of 11/09/2022. Revrew of recorqs for Staff I (Housekeeper), hired on 09/16/201.8, showed their BGI expired as of 09/09/2022. In an interview, on 10/17/2025 at 9:50.AM, Staff H (Area Business Office Manager) acknowledged that the BGI checks for Staff D .and Staff I had expired. This is an uncorrected deficiency previously cited on 08/18/2025. Plan/Attestation Statement I hereby certify that I have reviewed this report and have taken orwill take active measures to correct this deficiency. By takj.ng this action, Aerias L \iv ing Shore.·l!g_e is or will h:\ 0~ . be in compliance with this law and I or regulafron on (Date) I ln addition, I will implement a system to. monitor and ensure continued compliance with this requirement. Date This document was prepared by Residential Care Services for the Locator website. 08.18.2025 10:59:01 State of Washington 6/21 STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALT H SERVICES AGING AND LONG-TERM SUPPORT ADMlf\JISTRATION 20311 52ndAve W, Suite 100, Lynnwood, WA 98036 Statement of Deficiencies License#: 2592 Compliance Determination # 63404 Plan of Correction Aegis Living Shoreline Completion Date Page 1 of 9 Licensee: 14900 1s1 Ave Shoreline LLC 08/18/2025 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 the unannounced on-site full inspection on 07/30/2025 and 08/01/2025 of: Aegis Living Shoreline 14900 1ST AVENUE NE SHORELINE, WA 98155 The followi"ng sample was selected for review during the unannounced on-site visit: 10 of 94 current residents and 0 former residents. The department staff that inspected the Assi.sted Living Facility: Alma Duran, Licensor Keiko Kitano, Licensor From: DSHS, Aging and Long-Term Support Administration Residential Care Services, Region 2 , Unit J 20311 52nd Ave W, Suite 100 Lynnwooct, WA 98036 This document was prepared by Residential Care Services for the Locator website. 08.18.2025 10:59:01 State of Washington 7121 Statement of Deficiencies License #: 2592 Compliance Determination # 63404 Plan of Correction Aegis Living Shoreline Completion Date Page 2 of 9 Licensee: 14900 1s1 Ave Shoreline LLC 08/18/2025 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. 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. WAC 388-78A-2150 Signing negotiated service agreement. The assisted living facility must ensure that the negotiated service agreement is agreed to and signed at least annually by: (1) The resident, or the resident's representative if the resident has one and is unable to sign or chooses not to sign; This requirement was not met as evidenced by: Based on interview and record review, the Assisted Living Facility (ALF) failed to ensLire Negotiated Service Agreements (NSA) were signed annually for 3 of 10 sampled residents (Residents 1, 3, and 5). This failure placed Residents 1, 3, and 5 at risk for receiving care and services that were not agreed upon. Findings included ... Record review showed the ALF admitted Resident 1 on /2018 with multiple diagnoses. Review of the Individualized Service Plan (ISP - equivalent to a Negotiated Service Agreement), dated 04/15/2025: showed no signature from Resident 1 or their representative. Record review showed the ALF admitted Resident 3 on /2021 with multiple diagnoses. Review of the ISP, dated 04/15/2025, showed no signature from Resident 3 or their representative. Record review showed the ALF admitted Resident 5 on /2025 with multiple diagnoses. Review of the ISP, dated /2025, showed no signature from Resident 5 or their representative. This document was prepared by Residential Care Services for the Locator website. 08.18.2025 10:59:01 State of Washington 8121 Statement of Deficiencies License #: 2592 Compliance Determination # 63404 Plan of Correction Aegis Living Shoreline Completion Date Page 3 of 9 Licensee: 14900 1st Ave Shoreline LLC 08/18/2025 In an interview, on 08/04/2025 at 3:30 PM, Staff M (Health Services Director II) acknowledged that the ALF was unable to obtain the residents' or their representatives' signatures on the ISP for Residents 1, 3, and 5. 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, Aegi_s~iving horeline is or will be in compliance with this law and I or regulati.on on (Date}_.a..=u_._-=· ~--=~.-,c. In addition, I will implement a system to monitor and ensure continued compliance with this requirement. I I t:.i ?-l a.oa$ Date WAC 388-78A-2.305 Food sanitation. The assisted living facility must: (2) Ensure employees working as food service workers obtain a food worker card according to chapter 246-217 WAC; and This requirement was not met as evidenced by: Based on interview and record review, the Assisted Living Facility (ALF) failed to ensure 1 of 1 sampled staff (Staff C) had a food worker card (FWC). This placed 94 residents at risk for food borne illness. Findings included ... Review of staff records on 07/30/2025, showed that the ALF hired Staff C (Cook) on 06/17/2025. Review of Staff C's record showed no FWC. In an interview, on 07/31/2025 at 8:45 AM, Staff K (Area Business Office Manager) confirmed that Staff C did not have an FWC. This document was prepared by Residential Care Services for the Locator website. 08.18.2025 10:59:01 State of Washington 9/21 Statement of Deficiencies License #: 2592 Compliance Determination # 63404 Plan of Correction Aegis Living Shoreline Completion Date Page 4 of 9 Licensee: 14900 1st Ave Shoreline LLC 08/18/2025 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 horeline is or will be in compliance with this law and I or regulation on {Date} J- In addition, I will implement a system to monitor and ensure continued compliance with this requirement. Administrator (or Representative) WAC 388-78A-2474 Training and home care aide certification requirements. (1) The assisted living facility must ensure staff persons hired before January 7, 2012 meet training requirements in effect on the date hired, including requirements in chapter 388-112A WAC. (2) nie assisted living facility must ensure all assisted living facility administrators, or their designees, and caregivers hired on or afte1· January 7, 2012 meet the long-term care worker training reqLtirements of chapter 388-112A WAC including but not limited to: 1 (c) Specialty for dementia, mental illness and/or developmental disabilities when serving residents with any of those primary special needs; (d) Cardiopulmonary resuscitation and first aid; and (e) Continuing education. (3) The assisted living facility must ensure that all staff receive appropriate training and orientation to perform their specificjob duties and responsibilities. This requirement was not met as evidenced by: Based on interview and record review, the Assisted Living Facility (ALF) failed to ensure tliat 3 of 3 sampled staff members (Staff A, C, and D), met the long-term care workers training requirements under Washington Administrative Code (WAC) 388-112A. This placed 94 residents in the ALF at risk of not receiving proper care and services from inadequately trained staff members and potentially compromised the residents' health conditions. • Findings included .... NOTE: Washington Administrative Code (WAC) 388-78A-2500 - Specialized training for mental illness. The assisted living facility must ensure completion of specialized training, consistent with chapter 388-112A WAC, to serve residents with mental illness, This document was prepared by Residential Care Services for the Locator website. 08.18.2025 10:59:01 State of Washington 10/21 Statement of Deficiencies License #: 2592 Compliance Determination # 63404 Plan of Correction Aegis Living Shoreline Completion Date Page 5 of 9 Licensee: 14900 1st Ave Shoreline LLC 08/18/2025 whenever at least one of the residents in the assisted living facility has a mental illness that is the resident's primary special need and is a person who has been diagnosed with or treated for an Axis l or Axis II diagnosis, as described in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. NOTE: WAC 388-78A-2510 - Specialized training for dementia. The assisted living facility must ensure completion of specialized training, consistent with chapter 388-112A WAC, to serve residents with dementia, whenever at least one of the residents in the assisted living facility has dementia that is the resident's primary special need and has symptoms consistent with dementia as assessed per WAC 388-78A-2090(7). NOTE: WAC 388-112A-0495 \Aflat are the specialty training and supervision requirements for long term care workers in adult family homes. assisted living facilities, and enhanced services facilities? Assisted living facilities. (4) If an assisted living facility serves one or more residents with special needs, the assisted living facility must ensure that a long-term care worker employed by the facility demonstrates completion of or completes and demonstrates competency in specialty training within 120 days of hire. However, if specialty training is not integrated with basic training, the specialty training must be completed within 90 days of completion of basic training. NOTE: WAC 388-78A-2450 Staff. (3) The assisted living facility must: (d) Maintain the following documentation on the assisted living facility premises, during employment, and at 1·east tv.10 years following termination of employment: (i) Staff orientation and training or certification pertinent to duties, including, but not limited to: (A) Training required by chapter 388-1"12A WAC; (C) Cardiopulmonary resuscitation; (D) First aid; DEMENTIA AND MENTAL HEALTH SPECIALTY TRAINING AND FACILITY ORIENTATION Review of the undated Resident Characteristics Roster (RCR) showed the ALF had been providing care and services for 94 residents. The RCR showed ten residents were identified witl1 cognitive impairment/ dementia/ Alzheimer's (a group of symptoms that affects memory, thinking and interferes with daily life), and nine residents with a diagnosis of . Record review showed the ALF hired Staff A (Registered Nurse) on 08/11/2024. Staff A's record showed no documentation of orientation to the facility upon hire or completion of the required Dementia and Mental Health (MH) specialty training within 120 days of their employment. CARDIOPULMONARY RESUSCITATION (CPR) AND FIRST AID CARD Review of staff records showed that the ALF hired Staff B (Caregiver) on 05/06/2025. Review of Staff B:s record showed no CPR and first aid certificates. This document was prepared by Residential Care Services for the Locator website. 08.18.2025 10:59:01 State of Washington 11/21 Statement of Deficiencies License #: 2592 Compliance Determination # 63404 Plan of Correction Aegis Living Shoreline Completion Date Page6 of9 Licensee: 14900 1st Ave Shoreline LLC 08/18/2025 Review of staff records showed that the ALF hired Staff D (Caregiver) on 03i29/2022. Review of Staff D's record showed no valid CPR and first aid certificates. 12 HOURS CONTINUING EDUCATION NOTE: WAC 388-112A-0611 Who is 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? (1) The continuing education training requirements that apply to certain individuals working in assisted living facilities are described in this section. (a) The following long term care workers must complete 12 hours of continLiing education by their birthday each year: (i) A certified home care aide (HCA); Review of staff records showed that the ALF hired Staff D (Caregiver) on 03i29/2022. Review of Staff D's record showed that they had not completed the 12 hours of tl1e continuing education (CE) credits between their birthdates, 10/16/2023 and 10/16/2024. In an interview, on 07/31/2025 at 8:45 AM, Staff K (Area Business Office Manager) acknowledged that Staff A did not complete the required dementia/MH training or facility orientation, there was no CPR/first-aid training for Staff B and D, and there was no CE training for Staff D between their birthdates. Plan/Attestation Statement I hereby certify that I have reviewed this report and have taken or will take active me~sures t~ correc~ this_deficiency. By taking_this action, Aegis Livinr Shoreline is or will be in compliance with this law and/ or regulation on (Date) { D/ Ow/- ~-0~:S- . In addition, I will implement a system to monitor and ensure continued compliance with this requirement. WAC 388-78A-2466 Background checks Washington state name and date of birth background check Valid for two years National fingetl)rint 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: This document was prepared by Residential Care Services for the Locator website. 08.18.2025 10:59:01 State of Washington 12/21 Statement of Deficiencies License #: 2592 Compliance Determination # 63404 Plan of Correction Aegis Living Shoreline Completion Date Page 7 of 9 Licensee: 14900 1s1 Ave Shoreline LLC 08/18/2025 (a) A new DSHS background authorization form is submitted to the department's background check central unit every tv✓o years for all administrators, caregivers, staff persons, volunteers and students; and This requirement was not met as evidenced by: Based on interview and record review, the Assisted Living Facility (ALF) failed to ensure the Washington State name and date of birth background inquiry (BGI) for 2 of 2 sampled staff (Staff D and Staff E) were renewed before the two-year expiration. This placed 94 residents at risk of receiving care from staff whose criminal background history was unknown. Findings included ... Review of records for Staff D (Caregiver), hired on 03/29/2022, showed their BGI expired as of 01/11/2023. Review of records for Staff E (Housekeeper), hired on 09/'16/2018, showed their BGI expired as of 09/09/2022. In an interview, on 07/31/2025 at 8:45 AM, Staff K (Area Business Office Manager) acknowledged that the BGls for Staff D and Staff E were expired. 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 acti.on., Aegis Livinq Shoreline is or will be in compliance with this law and/ or regulation on (Date) [C) / c} J 8-0'i!)S, In addition, I will implement a system to monitor and ensure continued compliance with this requirement. Administrator (or Representative) WAC 388-78A-2484 Tuberculosis Two step skin testing. Unless the staff person meets the requirement for having no skin testing or only one test, the assisted living facility choosing to do skin testing, must ensure that each staff person has the following two-step skin testing: (1) An initial skin test within three days of employment; and This document was prepared by Residential Care Services for the Locator website. 08.18.2025 10:59:01 State of Washington 13/21 Statement of Deficiencies License #: 2592 Compliance Determination # 63404 Plan of Correction Aegis Living Shoreline Completion Date Page 8 of 9 Licensee: 14900 1s1 Ave Shoreline LLC 08/18/2025 (2) A second test done one to three weeks after the first test. This requirement was not met as evidenced by: Based on interview and record review, the Assisted Living Facility (ALF) failed to complete the two step skin test screening for tuberculosis (TB) for 3 of 5 sampled staff members (Staff A,. B and C). This placed 94 residents at risk of exposure to a communicable disease, Findings included ... NOTE: Washington Administrative Code (WAC) 388-78A-2480 Tuberculosis-Testing-Required. (1) The assisted living facility must develop and implement a system to ensure each staff person is screened for tuberculosis within thre.e days of employment Record review showed that the ALF hired Staff A (Registered Nurse) on 08/11/2024. Staff A's record showed TB screening was done on 11/03/2024, almost three months after hire date. Review of staff records showed that the ALF hired Staff B (Caregiver) on 05/06/2025. Staff B's record showed th~y did not complete the two step TB skin test. Review of staff records showed thatthe ALF hired Staff C (Cook) on 06/17/2025. Staff C's record showed a one-step negative TB skin test done on 06/28/2025 but did not complete the 2nd step TB skin test. In an interview, on 07/31/2025 at 8:45 AM, Staff K (Area Business Office Manager) acknowledged the ALF did not meet the required TB .skin test timely for Staff A, B, and C. This document was prepared by Residential Care Services for the Locator website. 08.18.2025 10:59:01 State of Washington 14/21 Statement of Deficiencies License #: 2592 Compliance Determination # 63404 Plan of Correction Aegis Living Shoreline Completion Date Page 9 of 9 Licensee: 14900 1st Ave Shoreline LLC 08/18/2025 Plan/Attestation Statement I hereby certify that I have reviewed this report and have taken or will take active me~sures t~ correc~ this_ deficiency. By taking _this actio_ n_,._ Aegis Livi~g Shoreline is or will be m compliance with this law and/ or regulation on {Date) 'Ol ~ l s.oas ' In addition, I will implement a system to monitor and ensure continued compliance with this requirement. ~ Administrator (or Representative)

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES Home and Community Living Administration PO Box 45600, Olympia, WA 98504-5600 November 10, 2025 ELECTRONIC-FACSIMILE Administrator Aegis Living Shoreline 14900 1ST AVENUE NE SHORELINE, WA 98155 Assisted Living Facility License # 2592 Licensee: 14900 1st Ave Shoreline LLC IMPOSITION OF CIVIL FINES Dear Administrator: On October 30, 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 civil fines on the license for your assisted living facility, also known as Aegis Living Shoreline, located at 14900 1ST AVENUE NE, SHORELINE, 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 October 30, 2025. Civil Fines WAC 388-78A-2474 (1)(2)(c)(d)(e)(3) Training and home care aide $400.00 certification requirements. The licensee failed to ensure that five staff members met the long-term care workers training requirements under Washington Administrative Code (WAC) 388-112A. This placed 91 residents in the facility at risk of not receiving proper care and services from inadequately trained staff members and potentially compromised the residents’ health conditions. This is an uncorrected deficiency previously cited on August 18, 2025. Administrator Aegis Living Shoreline License # 2592 November 10, 2025 Page 2 WAC 388-78A-2466 (1)(a) Background checks—Washington state $300.00 name and date of birth background check—Valid for two years—National fingerprint background check—Valid indefinitely. The licensee failed to ensure the Washington State name and date of birth background inquiry (BGI) for two staff members were renewed before the two-year expiration. This placed 91 residents at risk of receiving care from staff whose criminal background history was unknown. This is an uncorrected deficiency previously cited on August 18, 2025. 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: Jamie Singer, Field Manager Region 2, Unit J 20311 52nd Avenue West Suite 100 Lynnwood, WA 98036 Phone: (253) 312-1446 / Fax: (206) 971-6791 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). Administrator Aegis Living Shoreline License # 2592 November 10, 2025 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. You can make an IDR request and find directions on the IDR web page at: http://www.dshs.wa.gov/altsa/idr. 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 $700.00 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 Shoreline License # 2592 November 10, 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 Jamie Singer, Field Manager, at (253) 312-1446. Sincerely, Matt Hauser Compliance Specialist Residential Care Services Enclosure cc: Field Manager, Region 2, Unit J 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 20311 52nd Ave W, Suite 100, Lynnwood, WA 98036 Statement of Deficiencies License #: 2592 Compliance Determination # 36556 Plan of Correction Aegis Living Shoreline Completion Date Page 1 of 5 Licensee: 14900 1st Ave Shoreline LLC 02/08/2024 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 the unannounced on-site full inspection on 02/05/2024 and 02/07/2024 of: Aegis Living Shoreline 14900 1ST AVENUE NE SHORELINE, WA 98155 The following sample was selected for review during the unannounced on-site visit: 9 of 99 current residents and 0 former residents. The department staff that inspected the Assisted Living Facility: Sunny Kent, Licensor Scottie Sindora, ALF Licensor From: DSHS, Aging and Long-Term Support Administration Residential Care Services, Region 2 , Unit J 20311 52nd Ave W, Suite 100 Lynnwood, WA 98036 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 #: 2592 Compliance Determination # 36556 Plan of Correction Aegis Living Shoreline Completion Date Page 2 of 5 Licensee: 14900 1st Ave Shoreline LLC 02/08/2024 Administrator (or Representative) Date WAC 388-78A-2481 Tuberculosis Testing method Required. The assisted living facility must ensure that all tuberculosis testing is done through either: (1) Intradermal (Mantoux) administration with test results read: (a) Within forty-eight to seventy-two hours of the test; and (b) By a trained professional; or (2) A blood test for tuberculosis called interferon-gamma release assay (IGRA). This requirement was not met as evidenced by: Based on interview and record review, the Assisted Living Facility (ALF) failed to ensure an approved testing method was used to screen 1 of 5 sample staff (Staff A) for Tuberculosis (TB) within three days of hire. This failure placed 99 residents at risk for infection and increased health issues. Findings included… Record review of Staff A’s (Caregiver) personnel file showed the ALF hired him on 10/30/2023 as a full-time caregiver. Record review of Staff C’s TB record, undated, showed the Staff C received a chest X-ray on 8/22/2023. There was no indication Staff C had been screened for TB since that time. In an interview, on 01/23/2024 at 08:15 AM, Staff H (Business Office Manager) stated that she thought a chest x-ray was good for five years. 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 Shoreline 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. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2592 Compliance Determination # 36556 Plan of Correction Aegis Living Shoreline Completion Date Page 3 of 5 Licensee: 14900 1st Ave Shoreline LLC 02/08/2024 Administrator (or Representative) Date WAC 388-78A-2210 Medication services. (1) An assisted living facility providing medication service, either directly or indirectly, must: (a) Meet the requirements of chapter 69.41 RCW Legend drugs Prescription drugs, and other applicable statutes and administrative rules; and (b) Develop and implement systems that support and promote safe medication service for each resident. (2) The assisted living facility must ensure the following residents receive their medications as prescribed, except as provided for in WAC 388-78A-2230 and 388-78A-2250 : (a) Each resident who requires medication assistance and his or her negotiated service agreement indicates the assisted living facility will provide medication assistance; and This requirement was not met as evidenced by: Based on interview and record review, the Assisted Living Facility (ALF) failed to ensure medications services were implemented when 1 of 9 sample residents (Resident 5) missed 18 doses of a prescribed daily medication, and 1 of 9 sampled residents (Resident 9) who regularly refused two medications, continued documenting the medications as refused without contacting the resident’s primary care physician (PCP) for a discontinue order or advice from the PCP. This placed the residents at risk of harm from missed medications. Findings included… Record Review of the ALF’s “Resident Refusal of Medication Policy”, revised 04/21/2021, shows that if and when a resident refuses medication, staff must notify the prescriber in a manner and time frame as requested by the prescriber. Record review showed the ALF’s policy, “Limited Supply Ordering Back-up Medications Process”, revised on 03/27/2015, described a system to help eliminate situations where residents went without their prescribed medications. The Medication Care Manager (MCM) was responsible for obtaining medications from both the ALF’s preferred pharmacy, and any non-preferred pharmacy. RESIDENT 5 Record review of a Face Sheet, dated 02/05/2024, showed the ALF admitted Resident 5 on /2023 with diagnoses including ( This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2592 Compliance Determination # 36556 Plan of Correction Aegis Living Shoreline Completion Date Page 5 of 5 Licensee: 14900 1st Ave Shoreline LLC 02/08/2024 Further review of the eMARs showed Resident 9’s PCP prescribed a medication to treat flatulence. The PCP scheduled the medication for administration after meals at 9:00 AM, 12:00 PM, and 5:00 PM. Resident 9 refused the medication on 12/09/2023. Between 01/05/2024 and 02/04/2024, Resident 9 refused the medication 31 times. Reasons for refusal included, “Resident refused: declined taking medication since she was getting ready to leave”, “Resident refused: communicated that she did not need this med”, “Resident refused: did not want to take this med today” and, “preferred not to take this med today”; Resident refused: did not need”, “Resident refused: Resident said these medications are not helping”, “Resident refused: did not want”, and, “Resident refused”. During an interview on 02/07/2024 at 1:35 PM, Staff I (Registered Nurse, Health Services Director) stated that if a resident continues to refuse a medication, the ALF sends a request to the PCP for orders to discontinue the medication. For the statin, Staff I reviewed records and stated that the request to discontinue was initiated in November and was “on hold”, waiting for Provider response, as of 02/06/2024. Staff I also stated that Resident 9’s pharmacy, a component of their managed care health system, was often slow and/or unresponsive to the ALF’s requests for orders or other information. 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 Shoreline 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.