Laurel Cove Community.

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES Aging and Long-Term Support Administration PO Box 45600, Olympia, WA 98504-5600 January 28, 2025 ELECTRONIC-FACSIMILE Administrator Laurel Cove Community 17201 15th Ave NE Shoreline, WA 98155 Assisted Living Facility License # 2389 Licensee: Santé Shoreline ALF Op Co LLC IMPOSITION OF CIVIL FINE Dear Administrator: On January 15, 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 Laurel Cove Community, located at 17201 15th Ave 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 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 January 15, 2025. Civil Fine WAC 388-78A-2260(1) Storing, securing, and accounting for medications. $400.00 The licensee failed to safely store medications for one resident who had a physician’s order requiring assistance. This failure resulted in the resident having access to medications and placed them at risk for ingesting medications they were not ordered to self-administer. This an uncorrected deficiency previously cited on October 24, 2024. NOTE: This is the violation, which resulted in the fine; see the attached Statement of Deficiencies for any additional violations. Administrator Laurel Cove Community License # 2389 January 28, 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: 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). 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 Laurel Cove Community License # 2389 January 28, 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 $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 Laurel Cove Community License # 2389 January 28, 2025 Page 4 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 PO Box 45600, Olympia, WA 98504-5600 March 25, 2025 ELECTRONIC-FACSIMILE Administrator Laurel Cove Community 17201 15th Ave NE Shoreline, WA 98155 Assisted Living Facility License # 2389 Licensee: Santé Shoreline ALF Op Co LLC IMPOSITION OF CIVIL FINE Dear Administrator: On March 12, 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 Laurel Cove Community, located at 17201 15th Ave 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 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 March 12, 2025. Civil Fine WAC 388-78A-2260 (1) Storing, securing, and accounting for medications. $700.00 The licensee failed to safely store medications for one resident who had a physician’s order requiring facility medication management. This failure resulted in the resident having unmonitored access to medications and placed them at risk for ingesting expired prescription medication. This an uncorrected and recurring deficiency previously cited on January 15, 2025, and October 24, 2024. NOTE: This is the violation, which resulted in the fine; see the attached Statement of Deficiencies for any additional violations. Administrator Laurel Cove Community License # 2389 March 25, 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: 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). 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 Laurel Cove Community License # 2389 March 25, 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 $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 Laurel Cove Community License # 2389 March 25, 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

Residential Care Services Investigation Summary Report Provider/Facility: Laurel Cove Community Provider Type: Assisted Living Facility License/Cert.#: 2389 Intake ID: 188388 Compliance Determination #: 63824 Region/Unit #: RCS Region 2 / Unit J Investigator: Michelle Mcglon Investigation Date(s): 08/07/2025 through 08/26/2025 Complainant Contact Date(s): Allegation(s): 1. The Named Resident (NR) was physically held during care by the Named Staff (NS) and Named Staff 2 (NS2), which may have contributed to bruises at the Assisted Living Facility (ALF). Investigation Methods: Sample: Total residents: 65 Resident sample size: 2 Closed records sample size: Observations: Identified resident Staff to resident interactions Resident to resident interactions Interviews: Identified resident Nursing staff Executive Director Record Reviews: State reporting log Facility policies Resident Records Staff training records Personnel files Investigation Summary: 1. In an interview, the ALF staff stated that the NR was physically aggressive. The ALF staff denied contributing to the NR's bruises. In an interview, the Memory Care Director stated that the NR was aggressive with care. In an interview, sampled residents denied being mistreated by the ALF staff. Record review showed the ALF failed to complete an updated assessment and Negotiated Service Agreement to include the NR's aggressive behaviors during care. See Statement of Deficiencies 388-78A-2100. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written This document was prepared by Residential Care Services for the Locator website. Failed Provider Practice Not Identified / No Citation Written 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. 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. 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. 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. 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. 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, Washington 98504-5600 December 13, 2024 (email) Licensee: Sante Shoreline AFL Op Co LLC Laurel Cove Community 17201 15th Ave NE Shoreline, WA 98155 IDR RESULTS ALF # 2389 Dear Provider: Thank you for participating in the Informal Dispute Resolution (IDR) process. During the IDR we addressed your disputes identified in your IDR Request in response to the Statement of Deficiencies (SOD) report dated October 10, 2024 . As discussed during the IDR, the following information was considered: (cid:120) All materials presented by the Assisted Living Facility ; (cid:120) All oral statements and explanations offered by the Assisted Living Facility; (cid:120) Records gathered by the Residential Care Services (RCS) regional staff. After careful review and consideration, I have decided not to make any changes to SOD report dated October 10, 2024. Next Steps: (cid:120) If you have not done so already, begin the process of correcting the disputed deficiency or deficiencies immediately. (cid:120) Contact the local field manager if you need clarification related to the SOD report. (cid:120) Within 10 calendar days after you receive this letter, complete, and return the “Plan/Attestation Statement” for all disputed deficiencies. o For each disputed deficiency, indicate the date you have or will have corrected each one. o Next to each disputed deficiency, sign and date certifying that you have or will correct each disputed deficiency. o Mail the “Plan/Attestation Statement” with original signatures to: Jamie Singer, Field Manager Residential Care Services Region 2, Unit J 20311 52nd Ave W, Suite 100 Lynwood, WA 98036 Fax: (206) 971-6791 (cid:120) You must complete corrections within 45 days or less if directed by the department after review of your proposed correction dates. If you have any questions, please contact me at Staci.dilg@dshs.wa.gov . Sincerely, Staci Dilg IDR Program Manager Residential Care Services cc: Regional Administrator, Region 2 Field Service Administrator, Region 2 Field Manager, Region 2 Unit J Statewide Long Term Care Ombudsman Regional Long Term Care Ombudsman Central File IDR File

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES Aging and Long-Term Support Administration PO Box 45600, Olympia, WA 98504-5600 November 4, 2024 ELECTRONIC-FACSIMILE Administrator Laurel Cove Community 17201 15th Ave NE Shoreline, WA 98155 Assisted Living Facility License # 2389 Licensee: Santé Shoreline ALF Op Co LLC IMPOSITION OF CIVIL FINE Dear Administrator: On October 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 Laurel Cove Community, located at 17201 15th Ave 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 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 October 24, 2024. Civil Fine WAC 388-78A-2210 (1)(a)(b)(2)(a)(b) Medication services. $700.00 The licensee failed to correctly transcribe physician’s orders for two residents. This failure resulted in one resident receiving their medication at the wrong time, and the other resident receiving additional doses of medications and contributed to a hospitalization. This is a recurring deficiency previously cited on February 1, 2023, and March 29, 2023. NOTE: This is the violation, which resulted in the fine; see the attached Statement of Deficiencies for any additional violations. Administrator Laurel Cove Community License # 2389 November 4, 2024 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: 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). 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 Laurel Cove Community License # 2389 November 4, 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 $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 Laurel Cove Community License # 2389 November 4, 2024 Page 4 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 SN

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES Aging and Long-Term Support Administration PO Box 45600, Olympia, WA 98504-5600 November 4, 2024 ELECTRONIC-FACSIMILE Administrator Laurel Cove Community 17201 15th Ave NE Shoreline, WA 98155 Assisted Living Facility License # 2389 Licensee: Santé Shoreline ALF Op Co LLC IMPOSITION OF CIVIL FINE Dear Administrator: On October 24, 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 Laurel Cove Community, located at 17201 15th Ave 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 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 October 24, 2024. Civil Fine WAC 388-78A-2350 Coordination of health care services. $500.00 The licensee failed to notify the resident’s physician when one resident had a documented allergy to iodine and worsening skin breakdown. This failure resulted in the resident not receiving appropriate treatment and worsening skin breakdown. This is an uncorrected deficiency previously cited on September 10, 2024. NOTE: This is the violation, which resulted in the fine; see the attached Statement of Deficiencies for any additional violations. Administrator Laurel Cove Community License # 2389 November 4, 2024 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: 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). 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 Laurel Cove Community License # 2389 November 4, 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 $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 Laurel Cove Community License # 2389 November 4, 2024 Page 4 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 SN