Health inspection·November 24, 2025

The following reflects the findings of the California Department of Public Health during the investigation of a facility-reported incident number 2579861. Survey Event ID: 1D1E13-H1 State Citation AA 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. § 72527(a)(10) To be free from mental and physical abuse. On 7/28/25, the California Department of Public Health (CDPH) conducted a survey and found that a resident was sexually assaulted by another resident and the facility failed to intervene in the sexual assault. Based on observation, interview, and record review, the facility failed to keep one resident, Resident 47, free from sexual abuse a second time when Certified Nursing Assistant (CNA) 1 witnessed Resident 47 being sexually abused by Resident 2 and then closed the door without intervening, leaving Resident 47 at risk for further abuse by Resident 2. During a review of Resident 47's "Admission Record" dated 7/29/25, the "Admission Record" showed Resident 47 was admitted to the facility in December 2018. During a review of Resident 47's Quarterly Minimum Data Set (MDS - an assessment tool used to guide care), dated 6/5/25, MDS showed Resident 47 had multiple diagnoses that included Huntington's Disease (brain disorder that causes involuntary movements cognitive decline, and behavioral changes), non-Alzheimer's dementia (a condition that causes decline in cognitive abilities such as thinking), and depression. The MDS also indicated, Resident 47 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 review of Resident 47's "Care Plan" dated 12/14/18, the "Care Plan" indicated, Resident 47 had a diagnosis of Huntington's Disease and required dependent assist with two or more staff due to choreic (involuntary, jerking) movements. The "Care Plan" also indicated, Resident 47 was at risk for victimization (any unwanted or forced sexual activity, ranging from unwanted physical contact to rape) and one of Resident 47's goals was to maintain dignity and self-esteem. Resident 47's "Care Plan" did not show an active intervention that addressed risk for victimization. During a review of Resident 47's "Post Event Assessment Form," dated 7/26/25, under "B. Situation 1. Description of the event/Why the doctor is being called" indicated, "CNA 1 reported that he saw [Resident 47's] room door shut. He checked and saw Resident 2 with his pants down and had Resident 47's private area in his [Resident 2's] mouth..." During a review of Resident 47's "Nursing Progress Notes", dated 7/26/25, the "Nursing Progress Notes" indicated "...staff reported that he saw [Resident 47's] room door shut. He checked and saw Resident 2 with his pants down and had Resident 47's private area in his [Resident 2's] mouth..." During a review of Resident 2's "Admission Record", dated 7/29/25, the "Admission Record" indicated Resident 2 was originally admitted to the facility in December 2020 and was readmitted in August 2022. During a review of Resident 2's Annual MDS, dated 5/15/25, the MDS showed Resident 2 had multiple diagnoses that included impaired cognitive functions and awareness (inability to think, remember, and function independently leading to poor judgment, and emotional and behavioral changes.) During a review of Resident 2's "Care Plan" dated 8/9/22, the "Care Plan" indicated Resident 2 was at risk for physical altercations, property destruction and inappropriate sexual behavior. The "Care Plan" also indicated, Resident 2 made comments of a sexual nature and masturbated in front of staff. The "Care Plan" also indicated one of the interventions were, "Provide firm, direct verbal behavior if Resident 2 displays over familiar or inappropriate sexual behavior such as asking staff for sex or exposing his penis.". During a review of Resident 2's "Post Event Assessment Form," dated 7/26/25, under "B. Situation 1. Description of the event/Why the doctor is being called" indicated, "Staff reported that he saw peer [Resident 47] room door shut. He checked and saw Resident 2 with his pants down and had peer's [Resident 47's] private area in his mouth..." During a review of Resident 2's "Nursing Progress Notes", dated 7/26/25, the "Nursing Progress Notes" indicated "...Staff reported that he saw peer [Resident 47's] room door shut. He checked and saw Resident 2 with his pants down and had peer's [Resident 47] private area in his mouth..." During an interview on 7/29/25 at 1:15 p.m. with CNA1, CNA 1 stated, when he opened the door to Resident 47's room, he saw Resident 2 with his pants pulled down to his legs. CNA 1 stated, Resident 2 had his head on Resident 47's private part. CNA 1 also stated, he left Resident 47's room to get help because Resident 2 was "a big guy.". During a concurrent observation and follow-up interview on 7/29/25 at 1:35 p.m. in Resident 47's room with CNA 1, CNA 1 demonstrated the incident. CNA 1 opened the door to Resident 47's room. CNA1 stated he saw Resident 2 with his pants pulled down to his legs. CNA 1 then walked towards Resident 47's bedside and stated he saw Resident 2 with his head over Resident 47's private area. CNA 1 added, he saw Resident 47's penis showing. CNA 1 further stated, he left Resident 2 in Resident 47's room because he was scared. During a concurrent observation and interview on 7/29/25 at 1:50 p.m., with Clinical Director (CD), in the security room, the video footage from 7/26/25 was reviewed. The video footage showed the following: 14:24:42 Resident 2 appeared at the bottom of the screen walking in the hallway. 14:24:48 Resident 2 looked towards Resident 47's room. 14:24:50 Resident 2 entered Resident 47's room. 14:24:56 Resident 47's door closed. 14:25:19 CNA 1 appeared on (bottom) screen and looked towards Resident 47's closed door. 14:25:47 CNA 1 opened Resident 47's door, partially stepped in. CNA 1 then stepped outside Resident 47's room. 14:25:57 CNA 1 closed Resident 47's door, walked towards Nursing station 3, then disappeared from the screen. CD confirmed CNA 1 closed the door and left Resident 2 inside Resident 47's room. CD stated, CNA 1 was afraid. 14:26:12 Resident 2 exited Resident 47's room. 14:30:16 Registered Nurse (RN) 1 looked into Resident 47's room from the hallway. 14:30:23 RN 4 looked into Resident 47's room from the hallway. 14:36:40 CNA 1, CNA 2, CNA 3, CNA 4 followed by RN 4, Licensed Vocational Nurse (LVN) 2, RN 1 all entered Resident 47's room. During a follow-up interview on 7/29/25 at 3:14 p.m. with CNA 1, CNA 1 stated, he closed the [Resident 47's] door because he was very scared of Resident 2 following him after he had witnessed Resident 2 sexually abusing Resident 47. During a telephone interview on 7/29/25 at 3:47 p.m. with RN 4, RN 4 stated, RN 1 reported to her that Resident 2 had his mouth in Resident 47's private area. RN 4 stated, she walked by Resident 47's room but did not go inside to assess Resident 47. During a concurrent interview and record review interview on 7/30/25 at 2:38 p.m., with CD, the SOC 341 form (form used in California to report suspected abuse of a dependent adult or elder person) completed by CNA1 and dated 7/26/25 was reviewed. CD confirmed CNA 1's statement under "C. REPORTERS'S OBSERVATIONS, BELIEFS, AND STATEMENTS..." indicated, "I put a resident in the shower and saw Resident 47's door shut. I opened the door and stepped in and saw Resident 2 with his pants down and had Resident 47's private area in his mouth..." During a telephone interview on 7/31/25 at 10:11 a.m., with Resident 47's Conservator (CSV), CSV stated, the facility notified her that another resident was giving Resident 47 "oral sex." CSV added, she was afraid for the safety and well-being of Resident 47 because this was not the first time Resident 47 was sexually abused in the facility. CSV further added, the facility was not doing enough to keep Resident 47 safe otherwise the abuse would not have happened again. CSV also stated, Resident 47 was vulnerable and was not able to scream or ask for help due to his condition. During a concurrent interview and record review on 7/31/25 at 4:09 p.m. with Director of Nursing (DON), DON stated Resident 47 was a high risk for victimization due to past incident of being abused by a former staff member at the facility. DON stated, there was no care plan to address risk of victimization, therefore no proper intervention was put in place to ensure Resident 47's safety and well-being. DON also stated, CNA 1 was not supposed to leave Resident 47 when he witnessed abuse happening. DON added, CNA 1 was expected to stay with Resident 47 and initiate a "code green" to alert other staff of the incident. During a telephone interview on 7/31/25 at 4:40 p.m., with CNA 2, CNA 2 stated on 7/26/25 at around 2:25 p.m., CNA 1 approached her in the hallway near the nursing station 1. CNA 2 stated, she followed CNA 1 inside room 28 where she was told by CNA 1 he saw Resident 2 with his pants down, bent over "sucking Resident 47's penis." CNA 2 added, she and CNA 1 did not immediately check on Resident 47's well-being. CNA 2 stated the expectation was to not leave Resident 47 alone, especially when CNA 1 saw Resident 47 being abused. CNA 2 added, we were supposed to stay with Resident 47 and call "code green" to alert other staff of the situation. During an interview on 8/1/25 at 9:18 a.m., with RN 1, RN 1 stated, CNA 1 should not have left Resident 47's room when abuse was happening because this placed the resident [Resident 47] at risk for further abuse. RN 1 further added, she did not check on Resident 47 right away after learning Resident 47 was sexually abused. During a review of facility's policy and procedure (P&P) titled, "Abuse Prevention and Reporting," undated, revealed under definitions: ...3. Sexual abuse - means non-consensual contact of any type with a resident. Sexual abuse includes, but is not limited to: *Unwanted intimate touching of any kind especially of breast or perineal area. *All types of sexual assault or battery, such as rape, sodomy, and coerced nudity... *Sexual contact is nonconsensual if the resident either: ...lacks the cognitive ability to consent;... ...6. Resident to Resident Abuse - Aggressive or inappropriate behavior by one resident towards another comprises resident-to-resident abuse. ...C. Sexual aggression -examples of sexually aggressive behavior include, but not limited to, saying sexual things, inappropriate touching/grabbing. The P&P also indicated under prevention: ...F. Staff is required to intervene, identify, and correct the situations where any type of abuse or suspected crimes may occur..." This violation presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.