South Hill Village, Assisted Living & Memory Care.

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES Aging and Long-Term Support Administration PO Box 45600, Olympia, WA 98504-5600 January 29, 2025 ELECTRONIC-FACSIMILE Administrator South Hill Village, Assisted Living & Memory Care 3117 E Chaser Lane Spokane, WA 99223 Assisted Living Facility License # 2480 Licensee: PSL Associates, LLC IMPOSITION OF CIVIL FINE Dear Administrator: On January 15, 2025, the Department of Social and Health Services (DSHS), Residential Care Services completed a Full Inspection and 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 South Hill Village, Assisted Living & Memory Care, located at 3117 E Chaser Lane, Spokane, 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-2210(2)(a) Medication services. $600.00 The licensee failed to ensure residents received their medication as prescribed for one resident. This failure contributed to the resident developing symptoms and requiring treatment and admission to the hospital. This is a recurring deficiency previously cited on June 23, 2023, and March 15, 2024, for subsection (2)(a). NOTE: This is the violation, which resulted in the fine; see the attached Statement of Deficiencies for any additional violations. Administrator South Hill Village, Assisted Living & Memory Care License # 2480 January 29, 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: Jessica Salquist, Regional Administrator Region 1, Unit B 8517 E Trent Ave, Suite 102 Spokane Valley, WA 99212-2329 Phone: (509) 323-7315 / Fax: (509) 921-2426 rcsregion1email@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 South Hill Village, Assisted Living & Memory Care License # 2480 January 29, 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 $600.00 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 South Hill Village, Assisted Living & Memory Care License # 2480 January 29, 2025 Page 4 If you have any questions, please contact Jessica Salquist, Regional Administrator, at (509) 323-7315. Sincerely, For: Matt Hauser Compliance Specialist Residential Care Services Enclosure cc: Field Manager, Region 1, Unit B RCS Regional Administrator, Region 1 HCS Regional Administrator, Region 1 DDA Regional Administrator, Region 1 WA LTC Ombuds Office of Financial Recovery, Vendor Program Unit HQ Central Files DRW HP

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES Home and Community Living Administration PO Box 45600, Olympia, WA 98504-5600 September 17, 2025 ELECTRONIC-FACSIMILE Administrator South Hill Village, Assisted Living & Memory Care 3117 E Chaser Lane Spokane, WA 99223 Assisted Living Facility License # 2480 Licensee: PSL Associates, LLC IMPOSITION OF CIVIL FINE Dear Administrator: On September 4, 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 South Hill Village, Assisted Living & Memory Care, located at 3117 E Chaser Lane, Spokane, 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 September 4, 2025. Civil Fine WAC 388-78A-2210 (1)(b)(2)(a) Medication services. $1,000.00 The licensee failed to ensure a safe medication system was in place for one resident. This failure resulted in medications not being given as prescribed and placed the resident at risk for health complications. This is a recurring deficiency previously cited on January 15, 2025, for subsection (2)(a), March 15, 2024, and June 23, 2023. NOTE: This is the violation, which resulted in the fine; see the attached Statement of Deficiencies for any additional violations. Administrator South Hill Village, Assisted Living & Memory Care License # 2480 September 17, 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: Stephanie Jenks, Field Manager Region 1, Unit B 8517 E Trent Ave, Suite 102 Spokane Valley, WA 99212-2329 Phone: (509) 993-7821/ Fax: 509-921-2426 rcsregion1email@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 South Hill Village, Assisted Living & Memory Care License # 2480 September 17, 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 $1,000.00 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, 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 South Hill Village, Assisted Living & Memory Care License # 2480 September 17, 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 Stephanie Jenks, Field Manager, at (509) 993-7821. Sincerely, Matt Hauser Compliance Specialist Residential Care Services Enclosure cc: Field Manager, Region 1, Unit B RCS Regional Administrator, Region 1 HCS Regional Administrator, Region 1 DDA Regional Administrator, Region 1 WA LTC Ombuds Office of Financial Recovery, Vendor Program Unit HQ Central Files DRW HP

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.

—: WA DSHS report: Investigations (05/2024) —: WA DSHS report: Investigations (05/2024)

This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. Residential Care Services Investigation Summary Report Provider/Facility: South Hill Village, Assisted Provider Type: Assisted Living Facility Living & Memory Care License/Cert.#: 2480 Intake ID: 130803 Compliance Determination #: 41683 Region/Unit #: RCS Region 1 / Unit B Investigator: Anne Sinclair Investigation Date(s): 05/22/2024 through 05/29/2024 Complainant Contact Date(s): 05/22/2024, 05/24/2024, 05/28/2024 Allegation(s): Medication availability. Investigation Methods: Sample: Total residents: 143 Resident sample size: 3 Closed records sample size: 0 Observations: Identified resident Residents Activities Resident rooms Staff to resident interactions Resident to resident interactions Interviews: Identified resident Residents Regional Resident Care Coordinator Assistant Executive Director Resident Care Coordinator Resident Representative Record Reviews: Named Resident care plan/face sheet Named Resident May 2024 Medication Administration Record Sample residents care plan/face sheet Disclosure of Services Medication Administration Policy Characteristic roster Staff roster Provider orders Investigation Summary: Facility had addressed a concern that named resident's medication had not been initiated as ordered. Facility had a policy for medication administration, staff interviewed reported knowledge of process of medication availability and stated there had been an addressed error which had led to a delay of medication initiation for This document was prepared by Residential Care Services for the Locator website. named resident. Staff had been re-educated on medication availability and facility process for medications and orders, and record review showed named resident had received prescribed medication as ordered. Resident was placed on increased monitoring for new medication, named resident could make their needs known, and named resident interviewed had no concerns with their care needs including staff and medications. Residents interviewed stated no concerns with care needs, felt safe in the facility, and could talk to staff about concerns. Residents were observed without distress or unmet health needs and staff were assisting residents during unannounced facility visit. Consultation provided for WAC 388-78A-2240. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A This document was prepared by Residential Care Services for the Locator website.

—: WA DSHS report: Inspections (10/2023)