Peoples Senior Living Llc.

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written . N/A . Statement of Deficiencies License #: 2661 Compliance Determination # 57671 Plan of Correction Peoples Senior Living LLC Completion Date 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. 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. Administrator (or Representative) Date WAC 388-78A-2160 Implementation of negotiated service agreement. The assisted living facility must provide the care and services as agreed upon in the negotiated service agreement to each resident unless a deviation from the negotiated service agreement is mutually agreed upon between the assisted living facility and the resident or the resident's representative at the time the care or services are scheduled. This requirement was not met as evidenced by: Based on interview and record review the Assisted Living Facility (ALF) failed to provide showers as listed in the negotiated service agreements (NSA) for 1 of 3 residents (Resident 2 [R2]). This failure placed the residents at risk for skin infections and discomfort. Findings included… An interview on 04/08/2025 at 11:30 AM, R2 said they had not received two showers a week. Record review of R2’s shower records, dated 04/11/2025, showed documentation of three showers given out of the eight possible for the month of March 2025. Record review of R2’s NSA, initiated on 07/12/2024, showed two showers weekly with assistance. An Interview on 04/08/2025 at 1:30 PM with Staff A, Director of Nursing, said the facility had recently transitioned to a new tracking system and that some residents’ showers . Statement of Deficiencies License #: 2661 Compliance Determination # 57671 Plan of Correction Peoples Senior Living LLC Completion Date might not have been logged. 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, Peoples Senior Living LLC 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 .

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES Aging and Long-Term Support Administration PO Box 45600, Olympia, WA 98504-5600 March 6, 2025 ELECTRONIC-FACSIMILE Administrator Peoples Senior Living LLC 1720 E 67th St Tacoma, WA 98404 Assisted Living Facility License #2661 Licensee: Peoples Senior Living, LLC IMPOSITION OF CIVIL FINE Dear Administrator: On February 21, 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 Peoples Senior Living LLC, located at 1720 E 67th St, Tacoma, 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 February 21, 2025. Civil Fine WAC 388-78A-2810 (1)(2)(3) Criteria for increasing licensed bed $400.00 capacity. The licensee failed to submit to the Department of Health Construction Review Services (CRS), an application for review and approval for two rooms that were converted from office spaces to resident bedrooms, the addition of walls to three resident single occupancy apartments and the conversion of 43 single occupancy resident rooms to double occupancy. These failures prevented the department from having knowledge of the changes and placed all residents in rooms, not reviewed and approved by CRS safety at risk. This is an uncorrected deficiency previously cited on December 13, 2024. Administrator Peoples Senior Living LLC License # 2661 March 6, 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. Send your written request to: Informal Dispute Resolution Program Manager Residential Care Services PO Box 45600 Olympia, Washington 98504-5600 Administrator Peoples Senior Living LLC License # 2661 March 6, 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 Peoples Senior Living LLC License # 2661 March 6, 2025 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

This document was prepared by Residential Care Services for the Locator website.

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written . I&] □ N/A . D