Health inspection·October 23, 2025

The following reflects the findings of the California Department of Public Health during the investigation of a facility-reported incident and complaint numbers CA00927117 and CA00927980. Survey Event ID: 93XL11 State Citation A was written. §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must- §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; § 72315 (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. On 10/30/2024, at 10:45 a.m., an unannounced visit was conducted at the facility to investigate a facility reported incident and complaint regarding certified nursing assistant (CNA) sexually abusing Resident 1. Based upon observation, interview, and record review the facility failed to protect the residents from abuse when the facility did the following: 1. Failed to ensure Resident 1 was free from sexual abuse when CNA 1 (CNA 1) sexually abused Resident 1 twice in one day. This resulted in Resident 1 being sexually abused and had the potential for psychosocial harm. 2. Failed to properly monitor and supervise to ensure CNA 1 was not sexually abusing residents and specifically Resident 1. Resident 1's admission record, dated 1/22/25, indicated Resident 1 was admitted to the facility on 12/12/2018 for Huntington's disease (a disease in the brain which results in cognitive and functional decline) and paranoid schizophrenia (psychiatric disease which causes distrust of information and other people). The admission record indicated Resident 1 was conserved (court ordered arrangement which gives a conservator the power to make decisions for a person who is unable to do so for themselves) by family. A record review of Resident 1's minimum data set assessment (MDS, an assessment tool to guide resident care), dated 6/27/24, indicated Resident 1 was non-verbal, cognitively impaired, unable to make safe decisions, non-ambulatory (unable to move from one location to another independently) and was dependent on staff for all aspects of care including hygiene, toileting and feeding. During a record review of the facility map, dated 2/28/2017, the map indicated, on 8/18/25, Resident 1's room was located in a hallway two rooms away from the nurse's station. The nurse's station was located in a room at the end of the hallway. A record review of CNA 1's employment record indicated CNA 1 was employed at the facility from 8/8/22 to 10/23/24. During a record review of CNA 1's actual hours worked record titled, "[CNA 1] 1/22/2024-1/22/25," the record indicated CNA 1 had worked at the facility on 8/18/24, from 3:15 p.m. to 10:57 p.m.. The records indicated CNA 1 had worked eight days in August 2024, five days in September 2024 and one day in October 2024 for a total of 14 days in 2024. During a record review of facility staff assignment records titled, "PM Shift (evening shift)," dated from August 2024 to October 2024, the staffing records indicated CNA 1 was assigned to Resident 1 on August 7, 10, 11, 13, 16, 17 and 18. During an interview 10/30/24, at 10:45 a.m., with the Administrator (Admin) and the Director of Nursing (DON), the Admin stated, on 10/23/24, the facility received information from the police, that they had arrested CNA 1 and during a search of CNA 1's online storage account, found evidence that CNA 1 had sexually abused a resident. The police shared still images from the video which the DON was able to identify Resident 1 as the resident by identification of Resident 1's genitals and by wall postings and toys featured in Resident 1's room. During an interview on 11/1/24, at 10:00 a.m., with Resident 1's conservator, the conservator stated the police informed them of the sexual abuse. The conservator stated Resident 1 was not able to give consent to anything. The conservator stated Resident 1 would have rejected the advance by CNA 1 and "would've knocked the guy's block off if he was able." During a record review of the police report of Resident 1's sexual abuse case titled, "[City] Police Department Incident Report," dated 10/23/24, the report indicated police had searched CNA 1's online storage account and found on 8/18/24, CNA 1 had taken "two videos of an adult patient...both videos began with an adult diaper covering the patient's genitals...[CNA 1] folded the adult diaper down and exposed the patient's flaccid penis. [CNA 1] then manipulated the patient's [genitals] and masturbated the patient's [genitals]... [CNA 1] was wearing clear disposable gloves in the first video and was bare handed in the second video." The report indicated the facility was able to determine Resident 1 was the "patient" depicted in the videos and confirmed CNA 1's employment with the facility. The report indicated CNA 1 was charged with "Lewd Acts on a Dependent Adult by a Caretaker." During a review of facility policy and procedure (P&P) titled "Resident's Rights," undated, the P&P indicated "resident rights include the resident's right to the following:...be free from abuse." In violation of the above cited standards, the facility failed to ensure Resident 1 was free from sexual abuse. This failure resulted in Resident 1 being sexually abused and had the potential for psychosocial harm. This violation had a direct or immediate relationship to the health, safety or security of Resident 1.