Health inspection·November 17, 2022

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure two of two sample selected non-English speaking residents (Resident 108 and 110) had an appropriate communication system in place when Residents 108 and 110 did not have a written translation of vital information (communication board) at the bed side. Residents Affected - Some This failed practice resulted in Residents 108 and 110 not being able to communicate effectively with staff and to express their needs. Findings: A review of Resident 108's admission Record indicated Resident 108 was admitted to the facility with diagnosis of Hepatic encephalopathy (syndrome of impaired brain function occurring in patients with advanced liver diseases). During an observation and interview on 11/14/22 at 2:00 p.m., at Resident 108's room with Certified Nurse Assistant (CNA) 2, Resident 108 was observed not able to talk in English with the surveyor. CNA 2 confirmed Resident 108 was Spanish speaking and staff used sign language to communicate with Resident 108. CNA 2 was not able to find a communication board at Resident 108's bedside and did not know if the facility had a translation system in place or not. A review of Resident 110's admission Record indicated Resident 110 was admitted to the facility with diagnosis of heart failure (heart muscle does not pump blood as well as it should). During a concurrent observation and interview on 11/14/22 at 11:43 a.m., in Resident 110's room with CNA 3, Resident 110 was observed trying to talk to CNA 3, but CNA 3 was not able to understand. CNA 3 used sign language with Resident 110. CNA 3 stated she used sign language to communicate with non-English speaking residents and had no idea what other way is available to staff. CNA 3 further stated it is important to be able to communicate with residents to know about their needs. During an interview on 11/14/22 at 02:05 p.m., with Social Worker (SW) 1, SW 1 confirmed Residents 108 and 110 did not have a communication board in their own language at bedside. SW 1 was not able to communicate with Resident 110 and 108. SW 1 further stated it was important for the residents to be able to communicate with staff for their needs using their own language. A review of the facility's policy and procedure, Translation and/or Interpretation of Facility Services, revised May 2017, indicated, . 6. This facility shall provide Written translation of vital information pertaining to health services . 17. Staff shall be trained upon hire and at least annually on how to provide language access services to LEP (limited English proficiency) residents . Page 1 of 13 056345 056345 11/17/2022 San Leandro Healthcare Center 368 Juana Avenue San Leandro, CA 94577

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain the privacy for one (Resident 34) of 14 sampled residents when staff did not pull the privacy curtain when giving Resident 34 a bed bath. This deficient practice resulted in Resident 34 feeling his privacy was not honored. Residents Affected - Few Findings: A review of Resident 34's admission Record dated 11/17/22 indicated Resident 34 was admitted to the facility on [DATE] with a diagnosis of hemiplegia (a symptom that involves one-sided paralysis). A review of Resident 34's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 9/9/22 indicated Resident 34 was cognitively intact and required total dependence on one staff to bathe. During a concurrent observation and interview on 11/15/22 at 11:34 a.m. in Resident 34's shared room, Resident 34 was receiving a bed bath from Certified Nursing Assistant (CNA) 1. The privacy curtain was not pulled around to provide privacy and Resident 34 was fully exposed. Resident 34 can be seen by his roommate. CNA 1 stated he was providing a bed bath to Resident 34 and stated he forgot to provide privacy to Resident 34 by not pulling the privacy curtain. CNA 1 stated the privacy curtain should have been pulled all around to provide Resident 34 privacy during a bed bath. During an interview on 11/15/22 at 11:45 a.m. with Resident 34, Resident 34 stated he did not notice the privacy curtain was not pulled when he was receiving a bed bath because he was turned the other way, but stated he would hope that his privacy was honored. A review of the facility document titled, Quality of Life- Dignity, revised August 2009, indicated 10. Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. 056345 Page 2 of 13 056345 11/17/2022 San Leandro Healthcare Center 368 Juana Avenue San Leandro, CA 94577

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure to inform the ombudsman (an official appointed to investigate individuals' complaints against maladministration, especially that of public authorities) for one of three sample selected discharged residents (Resident 54) when, Resident 54 left the facility unplanned after signing an AMA (leaving Against Medical Advice). This failure practice had the potential for Resident 54 to be in an unsafe environment and not have access to medical intervention. Findings: A review of Resident 54's admission Record indicated Resident 54 was admitted to the facility on [DATE] with diagnosis of congestive heart failure (heart muscle does not pump blood as well as it should). During an interview on 11/17/22 at 10:02 a.m., with the Director of Nursing (DON), DON stated Resident 54 left the faciity on 9/20/22 unplanned when Resident 54's friend picked him up. DON stated Resident 54 signed the AMA form. DON further stated when residents leave the facility AMA, the facility does not give them their medications. During a telephone interview on 11/17/22 at 10:55 a.m., with Social Worker (SW) 2, SW 2 stated Resident 54 left the facility AMA and SW 2 did not know she had to notify the ombudsman. SW 2 further stated she thinks it is important to notify the ombudsman to follow up with the residents and make sure they are safe. A review of Resident 54's Statement of leaving without medical advise indicated Resident 54 left the faciity on 9/20/22 and signed the AMA form. A review of the facility's policy and procedure Transfer or Discharge Notice revised December 2016 indicated .4. A copy of the notice will be sent to the office of the State Long-Term Care Ombudsman . 056345 Page 3 of 13 056345 11/17/2022 San Leandro Healthcare Center 368 Juana Avenue San Leandro, CA 94577

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide an environment that was free from accidents for one (Resident 39) of one sample resident when the facility did not implement interventions to reduce the risk for falls for Resident 39 who had a history of frequent falls. This deficient practice had the potential for Resident 39 to experience a fall. Findings: A review of Resident 39's admission Record dated 11/17/22 indicated Resident 39 was admitted to the facility on [DATE] with a diagnosis of acute respiratory failure with hypoxia (impairment of gas exchange between the lungs and the blood causing low levels of oxygen in your body tissues). A review of Resident 39's Minimum Data Set (MDS, a tool to guide resident care) dated 4/30/22, indicated Resident 39 had one fall with no injury, one fall with injury and one major fall since admission. A review of Resident 39's Morse Fall Scale (a method of assessing a patient's likelihood of falling) indicated Resident 39 was at high risk to have a fall. A review of Resident 39's Care Plan (formal process that correctly identifies existing needs and recognizes potential needs or risks of a patient) indicated Resident 39 had frequent falls. The Care Plan also indicated an intervention to apply a sensor pad alarm in Resident 39's bed to alert staff of Resident 39's need of assistance. During a concurrent observation and interview on 11/16/22 at 2:06 p.m. with Licensed Vocational Nurse (LVN) 2, Resident 39 was asleep in bed with no sensor pad alarm. LVN 2 confirmed there was no sensor pad alarm in place. During an interview on 11/16/22 at 2:20 p.m. with Director of Nursing (DON), DON stated Resident 39 had frequent falls. DON stated Resident 39's Care Plan was updated recently to include the application of a sensor pad alarm in bed to alert staff of Resident 39's needs. DON stated the facility should be following Resident 39's Care Plan interventions to prevent falls for Resident 39. 056345 Page 4 of 13 056345 11/17/2022 San Leandro Healthcare Center 368 Juana Avenue San Leandro, CA 94577

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow its policies and procedures for oxygen administration and ensure oxygen supplies were maintained according to the operator's manual for three (Resident 39, 5, and 20) of four sampled residents receiving oxygen therapy, when staff did not document oxygen flow and rationale of Resident 39's oxygen therapy and Resident 39, 5, and 20's oxygen concentrator (an electronically operated device that separates oxygen from room air and provides high concentration of oxygen directly through a nasal cannula, a lightweight tube with one end split into two prongs which are placed in the nostrils and from which a mixture of air and oxygen flows) filter was covered with a thick layer of gray, fluffy matter. Residents Affected - Some This deficient practice had the potential for Resident 39, 5 and 20 to receive ineffective and inadequate oxygen therapy. Findings: A review of Resident 39's admission Record dated 11/17/22 indicated Resident 39 was admitted to the facility on [DATE] with a diagnosis of acute respiratory failure with hypoxia (impairment of gas exchange between the lungs and the blood causing low levels of oxygen in your body tissues). A review of Resident 39's Minimum Data Set (MDS, a tool to guide resident care) indicated Resident 39 was cognitively intact and received oxygen while a resident. A review of Resident 39's doctor's orders indicated an order on 12/24/21 for oxygen at 3 liters per minute via nasal cannula as needed for shortness of breath and/or to maintain oxygen saturation (amount of oxygen in the blood) greater than or equal to 92%. During a concurrent observation and interview with Licensed Vocational Nurse (LVN) 2 on 11/17/22 at 8:35 a.m., Resident 39 received oxygen at 5 liters per minute. LVN 2 confirmed Resident 39 received oxygen at 5 liters per minute (LPM). LVN 2 stated Resident 39's oxygen should be at 3 LPM. LVN 2 stated he does not know when Resident 39's oxygen was increased to 5 LPM because there was no documentation. During a concurrent record review and interview on 11/17/22 at 9:00 a.m., Resident 39's November 2022 Medication Administration Record (MAR) was reviewed with Director of Nursing (DON). Resident 39's November 2022 MAR did not indicate how many LPM of oxygen Resident 39 was receiving. DON confirmed there was no documentation from the staff to indicate how much LPM of oxygen Resident 39 was receiving. The facility document titled, Oxygen Administration, revised October 2022, indicated After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record: . 3. The rate of oxygen flow, route, and rationale. During a concurrent initial tour and interview with Maintenance Supervisor (MS) on 11/14/22 at 12:40 p.m., at Resident 5's bedside Resident 5 was observed using an oxygen concentrator. The concentrator had a filter on its side which was covered with a thick layer of gray, fluffy matter. MS stated Resident 5's concentrator filter was covered with a thick layer of dust, and it should be washed regularly. 056345 Page 5 of 13 056345 11/17/2022 San Leandro Healthcare Center 368 Juana Avenue San Leandro, CA 94577

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent observation and interview with LVN 1 on 11/15/22 at 10:15 a.m., Resident 39 was observed using a concentrator. Resident 39's concentrator filter was covered with a thick layer of gray, fluffy matter. LVN 1 stated the filter was filthy, and there should be a schedule for cleaning the filters. During an observation on 11/15/22 at 11:25 a.m., at Resident 20's bedside, Resident 20 was observed using an oxygen concentrator. The concentrator had a filter which was covered with a thick layer of gray, fluffy matter. During an interview with Assistant Administrator (AA) 1 on 11/15/22 at 11:50 a.m., AA 1 stated there should be a written cleaning schedule for the concentrators, including the filters. Review of the oxygen concentrator's Operator's Manual recommended cleaning the air filter every 7 days with mild dish soap (2 tablespoons) and warm water. 056345 Page 6 of 13 056345 11/17/2022 San Leandro Healthcare Center 368 Juana Avenue San Leandro, CA 94577

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview and record review, the facility failed to ensure pharmacy medication cart storage were clean and orderly, when various items were found in the narcotic box of Medication Cart (Med Cart) 1 and 2, and loose pills were found in Med Cart 1. This deficiency had the potential to result in medication diversion. Findings: During an inspection of Med Cart 2 on 11/16/22 at 11:20 a.m., the narcotic box had a plastic container which had a dirty wallet labeled with a resident's name, several loose coins, keys in a key ring, dollar bills, a cell phone, hearing aids and batteries, two wrist watches and a bag with 22 empty small medicine bottles. During an interview on 11/16/22 at 11:35 a.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated only narcotic medications were supposed to be in the narcotic box. During a concurrent inspection of Med Cart 1 on 11/16/22 at 12:50 p.m. and interview with LVN 3, the narcotic box had a plastic container with three pairs of hearing aids, a ring, a necklace, coins, and several letter envelopes which contained dollar bills. LVN 3 stated the narcotic box should be clean and not be used to secure personal items of residents. During an inspection of Med Cart 1 at 1:20 p.m. on 11/16/22, with LVN 3, 17 loose pills were found at the bottom of the left third drawer. LVN 3 state Med Cart 1 drawers had to have a cleaning schedule with a designated staff. During an interview with the Director of Nursing (DON) on 11/16/22 at 2:05 p.m., DON stated a cleaning schedule had to be set up for the medication carts, and no personal resident items should be kept in any area of the medication carts. The facility's policy and procedure titled, Preparation for Medication Administration, dated 2007 indicated, The nurse or authorized staff member on duty ensures equipment and supplies relating to medication storage and use are clean and orderly. 056345 Page 7 of 13 056345 11/17/2022 San Leandro Healthcare Center 368 Juana Avenue San Leandro, CA 94577

F 0800 Level of Harm - Minimal harm or potential for actual harm Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Based on observation, interview and record review, the facility failed to ensure 37 out of 37 residents with regular diet received enough protein on a regular basis. Residents Affected - Many This practice failure had a potential of malnutrition and protein deficiency for 37 residents on regular diet who were residing at the facility. Findings: During a concurrent observation and interview on 11/15/22 at 11:30 a.m., in the kitchen with Dietary Manager (DM), staff prepared dishes to serve residents with regular diet, fish was measured by the facility's scale and the weight of the fish was 2.1 oz (ounce, measurement) instead of 3 oz for regular diet. DM stated it was important to follow the protein measurements in the recipes because residents could have malnutrition or lose weight. DM stated she had no idea she had to follow the recipe for cooking size. DM confirmed 37 residents were on a regular diet at that time. During an interview and record review on 11/16/22 at 9:30 a.m., with Dietitian (D), D reviewed the recipe and stated kitchen staff had to use 4 oz fish for cooking and serving size should be 3 oz. D stated if residents do not receive enough protein, they could end up with malnutrition and other complications related to it. A review of Fall Menus dated 11/15/22 indicated the fish fillet was supposed to be serve in size of 3 oz for regular diet. A review of Recipe: fish fillet with garlic sauce indicated . Fish fillet 2 lb (pounds) for serving 8 (4 oz per person) . A review of the facility's policy and procedure Menu Planning dated 2020, indicated . One serving is three ounces of cooked meat, fish, or poultry without bone or fat . A review of the facility's policy and procedure Food Preparation dated 2018, indicated . To be sure portions served equal portion size listed on the menu . 056345 Page 8 of 13 056345 11/17/2022 San Leandro Healthcare Center 368 Juana Avenue San Leandro, CA 94577

F 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to obtain contracts, memorandum of understanding, or other agreements with third parties to provide dialysis services for three of four sampled residents (Resident 4, 43, 28) who were receiving dialysis treatments (the process of removing excess water, impurities from the blood of people whose kidneys could no longer perform these functions normally). This failure had the potential for Resident 4, 43, and 28 to receive inadequate or inappropriate dialysis care. Findings: A review of Resident 4's admission record dated 11/15/22 indicated Resident 4 was admitted to the facility on [DATE] with end stage renal disease (a medical condition in which a person's kidneys stop functioning on a permanent basis, leading to the need for dialysis or a kidney transplant), and dependence on renal dialysis. A review of Resident 4's order summary report dated 11/16/22 indicated Resident 4 was scheduled for dialysis at Dialysis Center 1 on Monday, Wednesday, and Friday from 9:30 a.m. to 1:30 p.m. A review of Resident 43's admission record dated 11/15/22 indicated Resident 43 was admitted to the facility on [DATE] with end stage renal disease, and dependence on renal dialysis. A review of Resident 43's order summary report dated 11/26/22 indicated Resident 43 was scheduled for dialysis at Dialysis Center 2 from 7:30 a.m. to 11:00 a.m. every Monday, Wednesday, and Friday. A review of Resident 28's admission record dated 11/15/20 indicated Resident 28 was admitted to the facility on [DATE] with end stage renal disease, and dependence on renal dialysis. A review of Resident 28's order summary report dated 11/16/22 indicated Resident 28 was scheduled for dialysis at Dialysis Center 3 from 12:30 p.m. to 4:00 p.m. every Tuesday, Thursday, and Saturday. During an interview with Assistant Administrator (AA) 2 on 11/16/22, at 8:45 a.m., AA 2 stated the facility did not have any agreements with Dialysis Center 1, 2, and 3 because it was not the facility's practice to enter into agreements with dialysis centers. 056345 Page 9 of 13 056345 11/17/2022 San Leandro Healthcare Center 368 Juana Avenue San Leandro, CA 94577

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 39's admission Record dated 11/17/22 indicated Resident 39 was admitted to the facility on [DATE] with a diagnosis of acute respiratory failure with hypoxia (impairment of gas exchange between the lungs and the blood causing low levels of oxygen in your body tissues) and urinary tract infection (UTI). Residents Affected - Some A review of Resident 39's doctor's orders indicated an order on 12/24/21 to not allow Resident 39's catheter tubing and drainage bag to touch the floor. During a concurrent observation and interview on 11/15/22 at 11:41 a.m., in Resident 39's room, Resident 39's Foley catheter (a thin, flexible tube placed in the bladder to drain urine) tubing was touching the floor. LVN 2 confirmed Resident 39's Foley catheter tubing was touching the floor. LVN 2 stated Resident 39's Foley catheter should not be touching the floor to prevent infection. A review of the facility policy and procedure titled, Catheter Care, Urinary, revised October 2010, indicated Infection Control 2 b. Be sure the catheter tubing and drainage bag are kept off the floor. 3. During a concurrent observation and interview on 11/14/11 at 10:14 a.m., a Contact Precautions Sign was posted outside of Resident 39's room. The Contact Precautions Sign stated to put on gloves and a gown before room entry and to discard the gloves and gown before room exit. There was no dedicated trash bin to place the used PPE in. DON confirmed there was no dedicated trash bin to place used PPE in. DON stated there should be a dedicated trash bin to place all used PPE in for infection control. A review of the facility policy and procedure titled, Personal Protective Equipment- Using Gowns, Revised October 2010, indicated 1. Use gowns only once and then discard into an appropriate receptacle inside the exam or treatment room . 8. After completing the treatment or procedure, gowns must be discarded in the appropriate container located in the room. Based on observation, interview and record review, the facility failed to ensure infection control policies and procedures were followed for one (Resident 39) of three sampled residents when: 1. Certified Nursing Assistant 1 (CNA 1) did not wear a gown while providing care for Resident 39 and CNA 1 did not perform hand hygiene after removing soiled incontinent briefs and applying clean briefs to Resident 39; 2. Resident 39's foley catheter (a thin, flexible tube placed in the bladder to drain urine) tubing was touching the floor; and 3. Resident 39's room did not have a dedicated PPE trash bin. These deficient practices had the potential to transmit infectious microorganisms and increase the risk of infection for residents and staff. Findings: 1. During a review of Resident 39's admission record, printed 11/17/22, the admission record 056345 Page 10 of 13 056345 11/17/2022 San Leandro Healthcare Center 368 Juana Avenue San Leandro, CA 94577

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some indicated Resident 39 was originally admitted to the facility on [DATE] with VRE Infection (VancomycinResistant Enterococci - can cause infections of the urinary tract, the bloodstream, wounds associated with catheters or surgical procedures, or other body sites.) During an observation on 11/15/22, at 11:37 a.m., the sign on the wall next to Resident 39's room number indicated, contact precautions (contact precautions prevent the spread of bacteria, parasites, and viruses from one person to another which can occur when touching an infected person and their dirty items, such as clothing, and surfaces) to be observed while entering the room. The sign indicated to wear gown and gloves before entering the room. During a concurrent observation and interview on 11/15/22, at 10:09 a.m., CNA 1 was observed providing bed bath to Resident 39 without wearing a gown. CNA 1 did not change his gloves and wash his hands after removing Resident 39's soiled incontinence briefs. CNA 1 proceeded to apply clean linens and briefs to Resident 39 with the same pair of gloves. CNA 1 stated he did not know he was supposed to don (put on) personal protective equipment (PPE) while caring for Resident 39. During an interview on 11/15/22 at 11:53 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated it is important to wear PPE as it is a part of infection control, and they must confine the infection and prevent it from spreading. LVN 1 stated the risk of not wearing PPE in a contact precaution room is the staff can get infected and spread the infection to other residents. During an interview on 11/16/22 at 11:35 a.m., with Director of Nursing (DON), DON stated it is unacceptable for staff to work with residents under contact precautions without wearing proper PPE and following infection control guidelines. DON stated it can lead to spread of infection. During a review of the facility's Policy and Procedure (P&P) titled, Infection Control guidelines for all Nursing procedures, revised on 04/2013, the P&P indicated, General guidelines . 2. Transmission- Based Precautions will be used whenever measures more stringent than Standard Precautions are needed to prevent the spread of infection .3. Employees must wash their hands for ten (10) to fifteen (15) seconds using antimicrobial or non- antimicrobial soap and wash under the following conditions .d, after handling items potentially contaminated with blood, body fluids, or secretions; . 5. Wear personal protective equipment as necessary to prevent exposure to spills or splashes of blood or body fluids or other potentially infectious materials. 056345 Page 11 of 13 056345 11/17/2022 San Leandro Healthcare Center 368 Juana Avenue San Leandro, CA 94577

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility had 18 rooms (Rooms 7, 8, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, and 25) with multiple beds that provided less than 80 square feet (sq. ft.) per resident who occupied these rooms. This deficient practice had the potential to result in inadequate space for the delivery of care to each of the residents in each room, or for storage of the residents' belongings. After observation and interview, there was adequate space for residents and staff to move about without obstruction. Recommend granting waiver. Findings: During an interview with the Assistant Administrator (AA) 1 on 11/14/22 at 1:00 p.m., the following rooms and corresponding square footage per bed were identified: Room Activity Room Size Floor Area 7 Bedroom [ROOM NUMBER] sq ft 71 sq.ft/bed 8 Bedroom [ROOM NUMBER] sq ft 70 sq.ft/bed 9 Bedroom [ROOM NUMBER] sq ft 70 sq.ft/bed 10 Bedroom [ROOM NUMBER] sq ft 70 sq.ft/bed 11 Bedroom [ROOM NUMBER] sq ft 72 sq.ft/bed 12 Bedroom [ROOM NUMBER] sq ft 73 sq.ft/bed 14 Bedroom [ROOM NUMBER] sq ft 73 sq.ft/bed 15 Bedroom [ROOM NUMBER] sq ft 73 sq.ft/bed 16 Bedroom [ROOM NUMBER] sq ft 73 sq.ft/bed 17 Bedroom [ROOM NUMBER] sq ft 73 sq.ft/bed 18 Bedroom [ROOM NUMBER] sq ft 73 sq.ft/bed 056345 Page 12 of 13 056345 11/17/2022 San Leandro Healthcare Center 368 Juana Avenue San Leandro, CA 94577

F 0912 19 Bedroom [ROOM NUMBER] sq ft 72 sq.ft/bed Level of Harm - Potential for minimal harm 20 Bedroom [ROOM NUMBER] sq ft 71 sq.ft/bed 21 Bedroom [ROOM NUMBER] sq ft 71 sq.ft/bed Residents Affected - Some 22 Bedroom [ROOM NUMBER] sq ft 71 sq.ft/bed 23 Bedroom [ROOM NUMBER] sq ft 71 sq.ft/bed 24 Bedroom [ROOM NUMBER] sq ft 71 sq.ft/bed 25 Bedroom [ROOM NUMBER] sq ft 71 sq.ft/bed During random observations of care and services from 11/14/22 through 11/17/22, there was sufficient space for the provision of care for the residents in all rooms. There was no heavy equipment kept in the rooms that might interfere with resident's care and each resident had adequate personal space and privacy. There were no complaints from the residents regarding insufficient space for their belongings. There were no negative consequences attributed to the decreased space and/or safety concerns in the 18 rooms. 056345 Page 13 of 13