Health inspection·February 27, 2020

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, facility staff failed to fully inform the responsible party (RP) of the current dental health status of one of 13 sampled residents (Resident 25). Residents Affected - Few This failure had the potential to result in Resident 25 developing an oral infection or gum disease, which could negatively impact her general health. Findings: During a record review on 2/25/20 of Resident 25's admission Record, printed 2/25/2020, the admission Record indicated Resident had an original admission date in 2008. The Record indicated Resident 25 had diagnoses which included generalized muscle weakness, and brain damage. The Record also indicated Resident 25 had a responsible party for healthcare decisions. During a review of Resident 25's Minimum Data Set (MDS, an assessment tool used to guide care), dated 10/26/19, the MDS indicated Resident 25 had severe impairment of her ability for daily decision making, and was totally dependent on assistance from one person for eating, toileting, and hygiene. During a review of Resident 25's care plan for oral/dental health concerns, undated, the care plan indicated an intervention of resident compliance with mouth care, with a goal of Resident 25 showing no signs of infection, pain, or bleeding in the mouth. During a review of Resident 25's care plan for intellectual disability, undated, the care plan intervention indicated, discuss with resident/resident and family any concerns, fears, issues regarding diagnosis or treatments. The care plan goal indicated, The resident/family/caregiver will be able to verbalize an understanding of the condition and the importance of compliance with the treatment program. During a review of Resident 25's records titled, Dental Visit, dated 2/12/19, the Dental Visit indicated, for an attempted dental cleaning, Patient combative-refused. The Dental Visits records dated 3/12/19, and 6/11/19, indicated Resident 25 refused cleaning on both occasions. During an observation on 2/25/2020, at 10:37 a.m., in Resident 25's room, Resident 25 was in her bed; Resident 25's teeth were brown and caked with debris. During an interview 2/25/2020, at 11:08 a.m., and 11:47 a.m., with the Social Services Director (SSD), the SSD stated Resident 25 had a court-appointed responsible party (RP). SSD stated the RP had to be informed and give approval for any special procedures or treatments needed by Resident 25. The SSD stated Resident 25 had been receiving dental cleanings at her bedside, but the dentist had told her Resident 25 needed a deeper cleaning than was possible to deliver at the bedside. During an interview on 2/25/2020, at 1:10 p.m., the RP stated she had been aware of Resident 25's poor dental hygiene, but had been told Resident 25 was receiving special mouth rinses and bedside dental care to provide the needed services. RP stated she had never been informed, either during her last visit on 1/8/2020, or by telephone, that Resident 25 had been refusing bedside dental care and needed special dental cleaning only available outside the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555341 If continuation sheet Page 2 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555341 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canyon Creek Post-Acute 22103 Redwood Road Castro Valley, CA 94546 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure the correct documentation for refusal of treatment was present in the medical record of one of eight sampled residents (Resident 46). The facility failure to change the medical record, to reflect a change in the status of Resident 46's wishes for treatment in the event of a medical emergency, had the potential to result in the undesired life sustaining treatment of cardiopulmonary resuscitation. (CPR, an emergency procedure that combines chest compressions with artificial ventilation (mouth to mouth breathing, or assisted breathing through a tube inserted into the throat.) Findings: During a review of Resident 46's Social Work Progress Notes, dated [DATE], the Notes indicated Resident 46 had been re-admitted from an acute care hospital with included diagnoses of dementia (a progressive deterioration of the brain functions affecting the abilities to remember, think clearly, communicate, and perform daily activities), and kidney failure. During a review of Resident 46's medical record on [DATE], at 8:55 a.m., the record contained a form titled, Physician Orders for Life-Sustaining Treatment, (POLST, a portable medical order form that records patients' treatment wishes so that emergency personnel knows what treatment the patient wants in the event of a medical emergency), dated [DATE]. The POLST indicated Resident 46 was to have CPR if the resident had no pulse and was not breathing and was to receive full treatment to prolong life by all medically effective means. During a review of the Physician's Orders, dated [DATE], the Physician's Orders indicated, Resident 46 was admitted with a primary diagnosis of dementia, to [company] Hospice Services. (Hospice services are provided for a person with a terminal illness whose doctor believes he or she has 6 months or less to live if the illness runs its natural course.) During a review of the [company] Hospice Care Services form (Hospice Form), dated [DATE], the Hospice Form indicated Resident 46 was not to receive CPR, but only receive comfort care. During a review of Resident 46's Social Work Progress Notes, dated [DATE], the Notes indicated Resident 49 was admitted into hospice care. The Notes indicated Resident 46's responsible party (a person who makes decisions regarding the resident's care in the facility when the resident is unable to make decisions) had signed the hospice admission agreement, and the facility would work with the hospice team to achieve a goal of comfort-directed care. During an interview, and concurrent record review, on [DATE] at 10:10 a.m., with the Director of Nursing (DON), and Social Services Director, the DON stated a licensed nurse was required to follow the POLST in the medical record when a resident needed life sustaining treatments. DON confirmed the POLST currently in the medical record for Resident 46 indicated Resident 46 should receive CPR, in the event her heart or lungs stopped. During a review of the facility's policy and procedure (P & P) titled, Emergency Procedure Cardiopulmonary Resuscitation, dated [DATE], the P & P indicated, If an individual .is found unresponsive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555341 If continuation sheet Page 3 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555341 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canyon Creek Post-Acute 22103 Redwood Road Castro Valley, CA 94546 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0578 Level of Harm - Minimal harm or potential for actual harm and not breathing normally, a licensed staff member who is certified in CPR/BLS (Basic Life Support) shall initiate CPR unless: 7. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR .exists for that individual Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555341 If continuation sheet Page 4 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555341 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canyon Creek Post-Acute 22103 Redwood Road Castro Valley, CA 94546 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 Level of Harm - Minimal harm or potential for actual harm Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on observation, interview, and record review, the facility failed to provide notification of the need to alter the dietary treatment for one of 14 residents (Resident 100). Residents Affected - Few The failure to inform the physician of Resident 100's refusal, for four days, to complete the infusion of the ordered liquid tube feeding (provision of nutrition and hydration through a tube inserted into the stomach, for residents unable to orally ingest sufficient quantities to support daily needs), had the potential to result in weight loss, body chemistry imbalance, and negatively impact general health status. Findings: During a review of Resident 100's admission Record, printed 2/24/2020, the admission Record indicated Resident 100 was admitted to the facility the previous week, with an included diagnosis of difficulty swallowing. The admission Record indicated Resident 100 was her own responsible party. During a review of Resident 100's Medication Review Report (MRR), dated 2/20/2020, the MRR indicated Resident 100 had a physician order dated 2/19/2020 for Resident 100 to receive a daily volume of 1000 milliliters (ml) of a liquid nutrition formula at a rate of 50 ml per hour. During a review of Resident 100's Total Intake and Output Record (I & O), the I & O indicated Resident 100 received the following volumes of liquid nutrition by a tube feeding: 2/20/2020 equaled 440 ml; 2/21/2020 equaled 440 ml; 2/22/2020 equaled 400 ml; 2/21/2020 equaled 800 ml; 2/23/2020 equaled 620 ml. During an observation and concurrent interview, on 2/25/2020, at 8:03 a.m., with Licensed Vocational Nurse 2 (LVN 2), Resident 100's tube feeding was turned off. LVN 2 stated Resident 100's tube feeding was turned off because the resident refused to receive the tube feeding. During an interview on 2/25/20 at 8:15 a.m., with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated on 2/23/2020, she had tried to administer the tube feeding to Resident 100, but Resident 100 had refused the tube feeding. LVN 3 stated Resident 100 had only allowed her to administer the tube feeding for two hours, last night (2/25/2020) between 12 a.m. and 2 a.m., before Resident 100 had refused the tube feeding. During a review of Resident 100's Nursing Care Notes, the Notes indicated nursing staff documented Resident 100 refused tube feedings on the following occasions: 2/23/2020, during the day shift (7 a.m. to 3:30 p.m. shift); 2/23/2020, during the evening shift (3 p.m. to 11:30 p.m.); 2/23/2020 night shift (11 p.m. on 2/23/2020 to 7 a.m. 2/24/2020); 2/24/2020 day shift; 2/24/2020 night shift. The Notes had no indication the physician was notified of these tube feeding refusals. During an interview on 2/25/20, at 8:25 a.m., with the Director of Nursing (DON), the DON stated the tube feeding refusals were not reported during the daily nursing meetings, or reported to the physician. During a review of the facility's policy and procedure (P & P) titled, Enteral Nutrition, dated January 2014, the P & P indicated, Adequate nutritional support through enteral feeding will be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555341 If continuation sheet Page 5 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555341 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canyon Creek Post-Acute 22103 Redwood Road Castro Valley, CA 94546 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete provided to residents as ordered .Staff caring for residents with feeding tubes will be trained on how to recognize and report complications relating to the administration of enteral nutrition . During another review of the facility's P & P titled, Requesting, Refusing and/or Discontinuing Care or Treatment, dated December 2016, the P & P indicated, .If a resident requests, discontinues or refuses care or treatment, the Unit Manager, Charge Nurse, or Director of Nursing Services will meet with the resident to: determine why the resident is requesting, refusing or discontinuing care or treatment; try to address the resident's concerns and discuss alternative options; and discuss the potential outcomes or consequences (positive and negative) of the resident's decision .The healthcare practitioner must be notified of refusal of treatment, in a time frame determined by the resident's condition and potential serious consequences of the request . Event ID: Facility ID: 555341 If continuation sheet Page 6 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555341 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canyon Creek Post-Acute 22103 Redwood Road Castro Valley, CA 94546 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Actual harm Based on observation, interview, and record reviews, the facility used bed rails and a position change alarm (bed alarm) for the convenience of staff, to prevent one of 13 residents (Resident 48) from voluntarily leaving his bed, and failed to re-evaluate the ongoing need for use of the restraining devices. This failure resulted in psychological and emotional distress for Resident 48, who was afraid to move around in bed, and had the potential to result in injury if he became entangled in the bed rails, or attempted to climb over the bed rails. Residents Affected - Few Findings: During a review of Resident 48's admission Record, printed 2/25/2020, the admission Record indicated an admission date in January 2019, with included diagnoses of hemiplegia (paralysis of the right side of his body), and generalized muscle weakness. The admission Record indicated Resident 48 had a responsible party (RP) for healthcare decisions. During a review of the Annual Minimum Data Set (MDS, a resident assessment tool used to guide care), dated 1/18/2020, the MDS indicated Resident 48 could understand others, and was understood by others, with moderate impairment of memory and thinking skills. The MDS indicated Resident 48 had no history of falling, but was unsteady, and required assistance from one person when transferring between surfaces, moving in bed, and ambulating. The MDS also indicated Resident 48 used either a walker, or wheelchair for ambulation. During a review of Resident 48's, Incident/Accident Report, dated 2/13/2020, the Report indicated a certified nursing assistant found Resident 48 on the floor on his right side. The Report indicated Resident 48 told the certified nursing assistant that he had gotten out of bed and fell. Resident 48 had an abrasion on his right elbow, but denied hitting his head. During a review of Resident 48's nurses' notes dated 2/14/2020, the notes indicated Resident 48 went to the acute care hospital for evaluation after he developed a persistent headache. During a review of Resident 48's nurses' notes dated 2/16/2020, the notes indicated Resident 48 returned to the facility from the acute care hospital with no new orders. During a review of the care plan titled, Fall Risk-Actual Fall, dated 2/13/2020, the care plan indicated interventions included reminding the resident to call for assistance, and bed alarm intact and working properly to alert when resident trying [to] get out bed unassisted. During a review of Resident 48's, Post Fall Assessment, dated 2/13/20, indicated a bed alarm was in place, and functioning well, to alert staff when Resident 48 tried to get out of bed unassisted. During a review of Resident 48's physician orders dated 2/18/2020, the physician ordered use of a bed alarm for Resident 48. During a concurrent observation and interview on 2/24/2020, at 10:08 a.m., with Resident 48, in his room. Resident 48 was in bed, flat on his back, watching television. Both sides of the bed had side rails elevated above the bed, along the length of the bed; a bed alarm was in place. Resident 48 stated he had fallen when he had gotten out of bed by himself to get something from his bedside table. He stated he had developed a headache after the fall, so he had gone to the hospital. Resident 48 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555341 If continuation sheet Page 7 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555341 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canyon Creek Post-Acute 22103 Redwood Road Castro Valley, CA 94546 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0604 Level of Harm - Actual harm Residents Affected - Few continued, When I came back from the hospital, they [facility staff] put this thing (pointed at bed alarm) that makes noise. I don't want to move, it [bed alarm] makes noise. They [facility staff)] said it's good for me, so they can hear me when I move. I just watch TV, and try not to move so it [bed alarm] does not make noise. During an observation and interview on 2/26/2020, at 8:26 a.m., with Resident 48 and Certified Nurse Assistant (CNA 2), in Resident 48's room, Resident 48 was in bed, on his back, with both side rails up. Resident 48 told CNA 2 he was not comfortable with the bed alarm. CNA 2 stated the bed alarm, and side rails were used to alert staff, because resident (Resident 48) was a fall risk, and had a tendency to get out of bed by himself. During an interview on 2/24/20, at 10:58 a.m., with the Director of Nursing (DON), in the facility's conference room, DON stated Resident 48's bed alarm was initiated after his fall on 2/13/2020, to alert staff when Resident 48 tried to get out of bed. During a concurrent observation and interview on 2/27/2020, at 8:56 a.m., with Licensed Vocational Nurse Supervisor (LVN 1) in Resident 48's room, Resident 48 was in bed with both side rails up. LVN 1 stated the bed rails were used to enable Resident 48 to move in bed more easily. LVN 1 asked Resident 48 to demonstrate how the bed rails enabled him to move in bed, but Resident 48 was unable to grab and hold onto the right hand side rail due to his right sided weakness. During a concurrent interview and record review on 2/26/2020, at 10:06 a.m., with the Director of Nursing (DON), the DON was unable to provide evidence of any evaluation process demonstrating the need for the continued use of Resident 48's bed alarm or side rails. During a review of the facility's policy and procedure (PNP), Use of Restraints, revised 12/2007, the PNP indicated, Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls .'Physical restraints' are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body .Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including: using bedrails to keep a resident from voluntarily getting out of bed as opposed to enhancing mobility while in bed .Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order all include the following: the specific reason for the restrant (as it relates to the resident's medical symptoms); how the restraint will be used to benefit the resident's medical symptom; and the type of restraint, and period of time for the use of the restraint. Orders for restraints will not be enforced for long than twelve (12) hours, unless the resident's condition requires continued treatment. Reorders are issued only after a review of the resident's condition by his or her physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555341 If continuation sheet Page 8 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555341 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canyon Creek Post-Acute 22103 Redwood Road Castro Valley, CA 94546 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for two of 14 sampled residents (Resident 7 and Resident 32), the facility failed to develop and implement a comprehensive care plan to address: 1. Resident 7's need for assistance with activities of daily living (ADL, the activities of dressing, eating, hygiene, toileting, mobility, ambulation, and bathing), and use of psychotropic medications (medication used to modify mental and/or emotional states). 2. Resident 32's need for assistance with ADLs, and use of psychotropic medications. These deficient practices had the potential to result in Resident 7 and Resident 32 not receiving the appropriate medical interventions necessary to meet the residents' nursing care needs. Findings: 1. During a review of Resident 7's admission Record, printed February 26, 2020, the admission Record indicated Resident 7 was admitted to the facility in July 2019 with diagnoses that included Alzheimer's Disease (a brain disorder that affects the ability to remember, think clearly, communicate, and perform daily activities and that may cause changes in mood and personality). During a review of Resident 7's Minimum Data Set (MDS, an assessment tool used to guide care), dated 2/20/20, the MDS indicated Resident 7 had severely impaired memory and thinking abilities, and required limited to extensive assist with ADLs. During a review of Resident 7's Medication Review Report, dated 2/1/2020-2/29/2020, the Medication Review Report indicated Resident 7 had a physician order, dated 9/26/19, for 75 milligrams (mg) of Seroquel, once a day, at bedtime, for depression, and an order dated 2/15/20, for 1 mg Ativan, every six hours when needed for anxiety. 2. During a review of Resident 32's admission Record, printed February 26, 2020, the admission Record indicated Resident 32 was admitted to the facility in April 2019, with diagnoses that included Alzheimer's Disease. During a review of Resident 32's MDS dated [DATE], the MDS indicated Resident 32 had severely impaired memory and thinking abilities, and required extensive assistance from at least one person for all ADLs. During a review of Resident 32's Medication Review Report, dated 2/1/2020-2/29/2020, the Medication Review Report indicated Resident 32 had a physician order, dated 4/19/19, for 3 mgs of Risperdal, twice a day, for depression, and an order dated 10/3/19, for 0.5 mgs Ativan, three times a day, for anxiety. During an interview on 2/26/20, at 9:33 a.m., with the MDS Coordinator (MDSC), MDSC stated, there were no care plans to address the needs of Resident 7 and Resident 32's ADLs. The MDSC stated care plan meetings were held at least quarterly for each resident, but Resident 7 and Resident 32's care plans for need for assistance with ADLs, were unintentionally missed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555341 If continuation sheet Page 9 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555341 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canyon Creek Post-Acute 22103 Redwood Road Castro Valley, CA 94546 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview and record review on 2/26/20, at 11:07 a.m., with the MDSC, the MDSC was unable to provide documented care plans for Resident 7 and Resident 32's anxiety and depression, and the use of psychotropic medications. MDSC stated both Resident 7 and Resident 32 needed care plans to address depression and anxiety. During an interview on 2/27/20, at 9 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated the MDSC was responsible for development of a resident's baseline care plans upon admission. LVN 1 also stated, the care plan was the guide for nursing staff to meet individual resident care needs. During a review of the facility's policy and procedure (P & P) titled, Care Plans, Comprehensive Person-Centered, dated 2016, the P & P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident .The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment .Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's condition change . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555341 If continuation sheet Page 10 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555341 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canyon Creek Post-Acute 22103 Redwood Road Castro Valley, CA 94546 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for one of 14 sampled residents (Resident 100), the facility failed to provide nursing services that met professional standards of quality when Resident 100 refused to receive the complete ordered dose of tube feedings (medical device used to provide nutrition when a person has trouble eating) for 3 days, and the medical doctor (MD) had not even been notified. Residents Affected - Few This deficient practice resulted in Resident 100 not receiving adequate nutrition through enteral feeding. Findings: During a review of Resident 100's admission Record, dated February 24, 2020, the admission Record indicated, Resident 100 was admitted to the facility on [DATE] with diagnoses of Schizoaffective Disorder (a chronic mental health condition). The admission Record indicated, Resident 100 is self-responsible. During a review of Resident 100's Medication Review Report, dated 2/20/2020, the Medication Review Report indicated, Resident 32 had an order on 2/19/20 that read, Enteral Feed Order two times a day Enteral Feeding: Fibersource HN (complete tube feeding formula with fiber) at 50 milliliter (ml)/hour times 20 hours equals to 1000 ml The Medication Review Report, further indicated an order on 2/19/20, Regular Diet Regular Texture, Regular thin consistency . During a review of Resident 100's Total Intake and Output Record, Three-Day Intake and Output Evaluation, dated 2/19/20 through 2/21/20, indicated, Resident 100 had an Average 24 Hour Intake of 683.3 mls and an Average 24 Hour Output of voiding (urinating) six times a day. The Total Intake and Output Record, Three-Day Intake and Output Evaluation, dated 2/22/20 through 2/24/20 indicated Resident 100 had an Average 24 Hour Intake of 616.7 mls and an Average 24 Hour Output of voiding (urinating) six times a day. During an observation on 2/25/20 at 8:03 a.m., Resident 100's tube feeding was noted off. During an interview with the Licensed Vocational Nurse (LVN) 2, immediately following the observation, LVN 2 stated, Resident 100's tube feeding was off at this time because the resident refused tube feeding administration. During another interview on 2/25/20 at 8:15 a.m., with the (LVN) 3, LVN 3 stated, tube feeding was administered on 2/25/20 between 12 a.m. to 2 a.m. until Resident 100 refused and requested to stop the tube feeding. LVN 3 stated, Resident 100 first refused tube feeding administration from LVN 3 on 2/23/20, and did not report to MD. LVN 3 stated, she should have reported to the MD. During a review of Resident 100's Nursing Care Notes, with different dates and times, from 2/20/20 through 2/25/20, indicated, Resident 100 refused tube feeding administration on multiple occasions from different licensed nurses, and neither one of the licensed nurses had notified the MD. During an interview on 2/25/20 at 8:25 a.m., with the Director of Nursing (DON), the DON stated he was not aware Resident 100 had been refusing tube feeding administration as ordered. The DON stated, when a resident refuses the second or third time, it is the licensed nurse's responsibility to report and inform the MD. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555341 If continuation sheet Page 11 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555341 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canyon Creek Post-Acute 22103 Redwood Road Castro Valley, CA 94546 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During a review of the facility's policy and procedure (P&P) titled, Enteral Nutrition, dated January 2014, the P&P indicated, Adequate nutritional support through enteral feeding will be provided to residents as ordered .Staff caring for residents with feeding tubes will be trained on how to recognize and report complications relating to the administration of enteral nutrition . During another review of the facility's P&P titled, Requesting, Refusing and/or Discontinuing Care or Treatment, dated December 2016, the P&P indicated, .If a resident requests, discontinues or refuses care or treatment, the Unit Manager, Charge Nurse, or Director of Nursing Services will meet with the resident to: determine why the resident is requesting, refusing or discontinuing care or treatment; try to address the resident's concerns and discuss alternative options; and discuss the potential outcomes or consequences (positive and negative) of the resident's decision .The healthcare practitioner must be notified of refusal of treatment, in a time frame determined by the resident's condition and potential serious consequences of the request . Event ID: Facility ID: 555341 If continuation sheet Page 12 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555341 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canyon Creek Post-Acute 22103 Redwood Road Castro Valley, CA 94546 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, facility staff did not develop and implement a communication plan for a non-English speaker, for one of 13 sampled residents (Resident 14). Residents Affected - Few For Resident 14, this failure had the potential to result in emotional distress, and unmet care needs. Findings: During a review of Resident 14's admission Record, printed on 2/25/2020, the Record indicated the facility admitted Resident 14 in 2018, with included diagnoses of generalized muscle weakness, with paralysis of the right side. The Record also indicated her primary language was Chinese, and Resident 14 had a responsible party for healthcare decisions. During a review of Resident 14's, Minimum Data Set (MDS, an assessment tool used to guide care), dated 9/28/18, the MDS indicated Resident 14 was totally dependent on assistance from one person for bed mobility, eating, toileting and personal hygiene. The MDS indicated Resident 14 was non-English speaking, had unclear speech, was rarely/never understood, but sometimes could understand others. During a review of Resident 14's care plan for communication, undated, the care plan indicated the interventions of, Use alternative communication tools as needed, and provide translator/interpreter as necessary to communicate with the resident. During an observation and concurrent interview on 2/25/2020 at 8:00 a.m., while in a common hallway with Licensed Vocational Nurse 4 (LVN 4), Resident 14 yelled while certified nursing assistants transferred her from her bed to a Hoyer lift (a mechanical device used to transfer residents with mobility issues from one surface to another) for transportation to the shower room. LVN 4 stated Resident 14 only spoke Chinese, and there was no communication book (either written words with translation in the resident's native language, or a picture book which allows residents to point at pictures to indicate needs) in her room. LVN 4 stated there was no staff in the facility that could interpret for the resident, but sometimes a family member would come to visit and would interpret for Resident 14. During an observation and concurrent interview on 2/25/2020, at 8:20 a.m., in the hallway outside Resident 14's room, with Certified Nursing Assistant 3 (CNA 3), Resident 14 yelled as she moved back to her room from the shower room. Resident 14 yelled while seated in the Hoyer lift, with her genitals visible, and urinated onto the floor, while continuing to yell. CNA 3 stated that Resident 14, Yells out all the time, and staff do not know what she needs or wants. During an interview on 2/26/2020, at 9:16 a.m., the Director of Nursing (DON) stated Resident 14 yelled, and staff did not understand her. During a review of the facility policy and procedure (P & P) titled, Translation and/or Interpretation of Facility Services, revised 3/2012, the P & P indicated, This facility's language access program will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility. It is understood that providing meaningful access to services provided by this facility requires also that the LEP resident's needs and questions (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555341 If continuation sheet Page 13 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555341 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canyon Creek Post-Acute 22103 Redwood Road Castro Valley, CA 94546 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0676 are accurately communicated to the staff. Oral interpretation services therefore include interpretation from the LEP resident's primary language back to English. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555341 If continuation sheet Page 14 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555341 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canyon Creek Post-Acute 22103 Redwood Road Castro Valley, CA 94546 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to follow safe food practices when: Residents Affected - Some 1. Unpasteurized eggs were used to make soft-yolk, fried eggs for residents. 2. Freezer 2 had a temperature above zero degrees Fahrenheit (F): bread, waffles, and bread rolls inside the freezer were not solidly frozen; ice cream cups were liquified. 3. The facility ice machine had a white residue on the air intake filter. 4. The following items were stored unlabeled and undated, as follows: Refrigerator 2 had one 12-ounce jar of pickles with an unsealed lid; Freezer 1 had one unsealed box of 48 rainbow sherbet cups, and two individual 4-ounce cups of vanilla ice cream; Freezer 2 had one plastic bag of frozen enchiladas, sealed by knotting the plastic bag; four frozen bags of peas; one 32-ounce bag of frozen cauliflower; and five 40-ounce bags of frozen brussel sprouts; Refrigerator 1 had one tray of four-ounce plastic glasses of both water and juice, and four trays of four-ounce plastic glasses containing milk. These failures placed all residents who ate/drank these products, or received ice, at risk of food-borne illnesses. Findings: 1. During a review of the facility, Good For You Health Menus, dated February 24 to March 1, 2020, the menu indicated breakfast included fried eggs on 2/24/2020. During a review of the facility recipe titled, Fried Egg/Hard Boiled Egg/Poached Egg, undated, the recipe indicated pasteurized eggs were to be used to make fried eggs. During an interview on 2/24/2020, at 12:45 p.m., with [NAME] 1, [NAME] 1 stated she had prepared fried eggs for 38 residents for breakfast on 2/24/2020. [NAME] 1 stated she used the shell eggs from Refrigerator 1 to make the fried eggs. [NAME] 1 stated she had prepared the fried eggs with soft yolks. During an interview on 2/24/2020, at 12:50 p.m., with Registered Dietician (RD), RD stated the eggs [NAME] 1 used for preparing the fried eggs for breakfast on 2/24/2020 were not pasteurized eggs. RD stated non-pasteurized eggs must have the yolk cooked to a hard consistency to avoid the risk of food-borne illness. During a review of the facility's policy and procedure (P & P) titled, Food Preparation, dated 2018, the P & P indicated pasteurized EEGs were to be used for fried eggs. 2. During a concurrent observation and interview on 2/24/2020, at 10:14 a.m., with RD, RD confirmed the outside thermometer of Freezer 2 registered 17 degrees F, while two of the inside thermometers registered 27 degrees F, and 17 degrees F, respectively. RD confirmed the status of the following items in Freezer 2: one vanilla ice cream cup contained melted ice cream; the waffles, pancakes, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555341 If continuation sheet Page 15 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555341 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canyon Creek Post-Acute 22103 Redwood Road Castro Valley, CA 94546 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some bread rolls were not solidly frozen. RD stated Freezer 2's temperature should be zero degrees F, or lower, to ensure the food inside remained frozen. During a concurrent interview and record review on 2/24/20, at 10:50 a.m., with [NAME] 1, Freezer 2's Cold Storage Temperature Log, dated February 2020, was reviewed. The Log morning entry for 2/23/2020 indicated a value of minus 8 degrees F; the evening entry indicated a value of positive 8 degrees F. [NAME] 1 stated she had entered the morning Log entry, but had mistakenly entered the value as minus 8 degrees F. [NAME] 1 stated the thermometer had actually registered 8 degrees F. During a concurrent interview and record review on 2/24/20, at 10:45 a.m., with [NAME] 2, Freezer 2's Cold Storage Temperature Log, dated February 2020, was reviewed. [NAME] 2 stated he had entered Freezer 2's outside thermometer value of positive 8 degrees F on the Log on 2/23/20 at 6:30 p.m. During a review of the facility's policy and procedure (P & P) titled, Procedure for Refrigerated Storage, dated 2018, the P & P indicated: freezer temperatures should be maintained at 0 degrees F, or lower; maintenance of a log with documentation of freezer temperatures twice a day, when opening and closing the kitchen. 3. During a concurrent observation and interview on 2/26/20, at 8:33 a.m., with Maintenance Manager (MM), the air intake filter on the ice machine was covered with a white substance. MM stated there was too much white substance on the filter and MM 1 would clean it soon. During a concurrent interview and record review on 2/26/20 at 8:33 a.m., with MM, the Bi-Monthly Ice Machine Cleaning Log, dated 2020, was reviewed. The Log indicated the ice machine had been cleaned 1/3/2020, and 2/7/2020. MM stated he had cleaned the ice machine once a month, as indicated on the Bi-Monthly Ice Machine Cleaning Log. During an interview on 2/26/20 at 8:40 a.m., with the facility Administrator (ADM), ADM stated the ice machine should be cleaned twice a month to prevent the spread of infection. During a review of the facility's policy and procedure (P & P) titled, Ice Machine Bi-Monthly Cleaning Procedures, undated, the P & P indicated the ice machine was to be cleaned bi-monthly. 4. During a concurrent observation and interview on 2/24/2020, at 8:15 a.m., with Dietary Aid (DA), in the facility kitchen, DA confirmed Freezer 2 contained the following undated and unlabeled food: one plastic bag of unlabeled enchiladas; four plastic bags of peas; one 32-ounce bag of cauliflower; and five 40-ounce bags of Brussels sprouts. DA stated one plastic bag of enchiladas, four plastic bags of peas, one 32-ounce bag of cauliflower; and five 40-ounce bags of Brussels sprouts were undated and unlabeled. During a review of the facility's policy and procedure (P & P) titled, General Receiving of Delivery of Food and Supplies, dated 2018, the P & P indicated all food items were to be labeled with a delivery date and time, and leftovers should be labeled and dated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555341 If continuation sheet Page 16 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555341 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canyon Creek Post-Acute 22103 Redwood Road Castro Valley, CA 94546 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure staff followed policy and procedures for hand hygiene for seven of 14 sampled residents (Residents 26, 35, 18, 30, 101, 2, and 49). The failure of Certified Nursing Assistant 1 (CNA) to perform required hand hygiene during the passing and setting up of the residents' lunch trays had the potential to result in illness, and the spread of illness for Residents 26, 35, 18, 30, 101, 2, and 49. Residents Affected - Some Findings: During a continuous observation on 2/24/2020, at 12:10 p.m., in the dining area, CNA 1 pushed the lunch tray cart into the dining area, and without performing hand hygiene (HH), picked up a lunch tray, delivered it to Resident 26, and removed the plate cover. CNA 1 returned to the meal cart, and without performing HH, picked up a lunch tray, delivered it to Resident 35, and removed the plate cover. CNA 1 returned to the tray cart, and without performing HH, picked up a lunch tray, and delivered it to Resident 18. CNA 1 removed Resident 18's plate cover, and the covers for the milk and water glasses. Without performing HH, CNA 1 went to the tray cart, picked up a lunch tray, delivered it to Resident 30, and took off the plate cover. Registered Dietician arrived in the dining area. Without performing HH, CNA 1 went to the tray cart, bent down, with one hands on her knee and the other on the lower part of the tray cart. CNA removed a lunch tray from the cart, delivered it to Resident 101, took off the plate cover, and sliced the vegetables for Resident 101. Without performing HH, CNA 1 went to the tray cart, picked up a lunch tray, delivered it to Resident 2, and removed the covers from the plate, and milk glass. Without performing HH, CNA 1 went to the tray cart which held consumed meal trays, and touched the plate cover from a consumed meal plate. Without performing HH, CNA 1 went to the kitchen, received a meal tray, delivered it to Resident 49, and removed the plate cover. During an interview on 2/24/2020 at 1:18 p.m., CNA 1 stated there had been no sanitizer in the dining area, so she had not performed HH between serving of the residents' lunch trays. During an interview on 2/24/2020 at 1:45 p.m., Registered Dietician (RD) stated she had observed CNA 1 touch her knees, and the consumed meal tray. RD stated CNA 1 should have performed HH after touching her knees and the consumed meal tray. During a review of the facility's policy titled, Handwashing/Hand Hygiene, dated August 2015, indicated staff should use alcohol based hand rub or soap and water before and after assisting a resident with meals and after handling contaminated equipment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555341 If continuation sheet Page 17 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555341 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canyon Creek Post-Acute 22103 Redwood Road Castro Valley, CA 94546 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

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 two resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) with two beds each that provided less than 80 square (sq.) feet (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 resident belongings. Findings: During an observation on 2/25/20 at 10:30 a.m., the following rooms and corresponding square footage per bed were identified: Resident room [ROOM NUMBER] (two-bed room) was 11 ft. by 14.5 ft. Each resident's personal space was 70.08 sq. ft. Resident room [ROOM NUMBER] (two-bed room) was 10.8 ft. by 14.4 ft. Each resident's personal space was 70.56 sq. ft. During random observations of care and services from 2/24/20-2/27/20, there was sufficient space for the provision of care for the residents in room [ROOM NUMBER] and room [ROOM NUMBER]. There was no heavy equipment kept in the rooms that might interfere with resident 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 two rooms. Granting of room-size waiver recommended. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555341 If continuation sheet Page 18 of 18