Non-compliance follow-up·August 19, 2025

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct a case management – legal/non-compliance visit. LPA met with General Manager (GM), Billy Mitchell and Health Services Director (HSD) Jocelyne Bailon Saloche. The purpose of the visit to ensure the facility is adhering to the compliance plan submitted to Community Care Licensing (CCL) after a non-compliance meeting held on June 13, 2024. During visit, LPA toured the facility with staff to include garden house (aka memory care), plaza, common areas. There were 14 staff members total on schedule during the AM shift in Prom/Plaza, and Garden House. LPA reviewed the facility's roster on Guardian and observed the 14 staff members are fingerprint cleared and associated to the facility. In Garden House, LPA randomly entered into rooms 111A, 116B, 120, 125B, 126A, and 126B with the Garden House Director. All the cabinets observed secured. No observation of accessible sharp objects, chemicals, disinfectants, and hygiene products to residents in care with dementia. In Plaza, LPA randomly entered into rooms 203, 209, 211, 301, 304, and 309 with the HSD. No issues were noted. Residents who store their own chemicals, disinfectants and hygiene products are able to store these items per their physician's report/records. Page 1 of 2. LPA observed all training topics stated on the non-compliance plan was completed on 02/19/2025 - fall policy; 06/19/2025 - resident rights, toxic chemicals, and fire & alarms; and 07/17/2025 - change of condition and mandated reporting. The training document contains the topic, date, name and signatures of the participants. LPA advised the GM to ensure all staff (including new staff members) are provided annual training on these specific topics per the non-compliance plan. 5 random resident files were reviewed and observed complete. 5 resident files contained a signed personal rights form, updated physician’s report, and a signed updated appraisal/needs and services plan. 5 random staff files were reviewed. 5 staff are fingerprint cleared and associated to the facility. LPA advised GM regarding the importance of adhering to the facility's corrective action plan that was developed on June 13, 2024, to ensure the facility's stays within compliance of Title 22 regulation. GM was reminded of the discussion on June 13, 2024 of the facility being under frequent monitoring inspection visits to ensure compliance with the compliance plan and Title 22 Regulations for 2 years. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with General Manager, Billy Mitchell and Health Services Director, Jocelyne Bailon Saloche and a copy of the report was provided. Page 2 of 2.