OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 02/24/26 at 10:50 am, the facility kitchen was observed to need cleaning in the following areas: * Floor beneath stove/grill and steamer – build up of black debris; * Top of dishwasher – build up of dried debris; * Wall under spray hose sink and behind dishwasher – build up of brown matter; * Wall above three compartment sinks – build up of dust; * Ceiling vents and surrounding ceiling above refrigeration units and near dishwasher – build up of dust; and * Side of grill – food spills/splatters. Other concerns included: * Two door refrigerator across from steam table – seal on bottom of door not connected; and * Commercial can opener – blade finish worn off. The areas of concern were discussed with Staff 1 (Director of Dining Services) on 02/24/26. The findings were acknowledged at 12:15 pm.

Tag C240 – Food Sanitation (OAR 333-150-0000) 1. Corrective Action for Specific Instances Identified On 02/25/2026, immediately following the exit conference, the following corrective actions were started: * The floor beneath the stove/grill and steamer was pulled out and deep cleaned to remove black debris. * The top of the dishwasher was cleaned and sanitized. * The wall under the spray hose sink and behind the dishwasher was cleaned and sanitized. * The wall above the three-compartment sink was cleaned to remove dust accumulation. * Ceiling vents and surrounding ceiling areas above refrigeration units and near the dishwasher were cleaned. * The side of the grill was degreased and sanitized to remove food splatters. * The two-door refrigerator gasket seal was ordered and when it is delivered maintenance will reattch before 3/15/26 * The commercial can opener blade will be replaced before 3/15/26 All cited areas were cleaned, repaired, or replaced by 3/2/26 2. Systemic Changes to Prevent Recurrence To ensure ongoing compliance with OAR 333-150-0000: * A revised Kitchen Deep Cleaning Schedule has been implemented effective 3/3/26 * Daily, weekly, and monthly cleaning assignments now include: * Moving and cleaning beneath cooking equipment * Cleaning tops of equipment * Cleaning walls behind and above sinks * Cleaning ceiling vents * A Preventative Maintenance Log has been implemented to monitor: * Refrigerator gaskets and seals (monthly inspection) * Small wares and equipment condition (including can opener blades) * The Director of Dining Services (DDS) will complete and sign off on a weekly sanitation audit checklist. * The Executive Director or designee will conduct a random monthly environmental sanitation audit for oversight. 3. Monitoring of Ongoing Compliance * Weekly kitchen sanitation audits will be completed by the DDS and reviewed by the Executive Director. * Monthly administrative oversight audits will be documented and retained for review. * Any identified concerns will be corrected immediately and documented. * Sanitation logs will be maintained for no less than 12 months. 4. Staff Training * All dietary staff were retrained on: * Oregon Food Sanitation Rules (OAR 333-150-0000) * Cleaning and sanitizing standards * Equipment maintenance reporting procedures * Training will be completed by completed 3/15/26 * New hires will receive sanitation protocol training during orientation. * Refresher training will occur quarterly.

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). This Rule is not met as evidenced by:

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C240.

Tag Z0142 – Administration Compliance (OAR 411-057-0140(2)) Corrective Action As Z0142 is derivative of C240: * Administrative oversight systems have been strengthened to ensure ongoing compliance with Residential Care and Assisted Living licensing rules. * The Executive Director has implemented a structured monthly environmental compliance review process. * A compliance binder has been created to house sanitation logs, maintenance records, and audit tools for survey readiness. Monitoring * Monthly compliance review meetings will be conducted with the Director of Dining Services. * Findings will be documented and corrective action taken immediately if needed. Date of Alleged Compliance: 03/15/2026 The facility alleges compliance with OAR 411-057-0140(2) by 03/15/2026.

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: