Health inspection·March 27, 2026

California Health & Safety Code, Section 1418.91 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. California Code of Regulation, WIC Section, Section15630 (b)(1) A mandated reporter who, in their professional capacity, or within the scope of their employment, has observed or has knowledge of an incident that reasonably appears to be physical abuse, as defined in Section 15610.63, abandonment, abduction, isolation, financial abuse, or neglect, or is told by an elder or dependent adult that they have experienced behavior, including an act or omission, constituting physical abuse, as defined in Section 15610.63, abandonment, abduction, isolation, financial abuse, or neglect, or reasonably suspects that abuse, shall report the known or suspected instance of abuse by telephone or through a confidential internet reporting tool, as authorized by Section 15658, immediately or as soon as practicably possible. If reported by telephone, a written report shall be sent, or an internet report shall be made through the confidential internet reporting tool established in Section 15658, within two working days. Code of Federal Regulation, Title 42, Section 483.12 (c)(1) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. On 2/24/26 at 10:01 a.m. an unannounced visit to the facility was conducted to investigate entity reported incident 2703313 regarding an allegation of abuse for one of three sampled residents (Resident 1). The Department determined the facility failed to report suspected abuse for one of three sampled residents (Resident 1) to The Department within the regulatory timeframe, when Resident 1's visitor/caregiver was reported as abusive on 1/31/26 to a mandated reporter and the incident was not reported until two days later on 2/2/26. This failure resulted in a delay of investigation of abuse which had the potential for abuse to continue causing increased emotional distress or mental anguish for Resident 1. A review of Resident 1's "Admission Record" indicated Resident 1 was admitted to the facility in March 2025 with multiple diagnoses including neuromuscular dysfunction of the bladder (loss of bladder control due to nerve damage), protein calorie malnutrition (decreased protein and calorie intake causing weight loss and nutritional deficiencies), dysphagia (difficulty swallowing), and congestive heart failure (heart does not pump blood as efficiently as it should). The "Admission Record " indicated Resident 1's visitor/caregiver was his Responsible Party (RP) and healthcare decision maker. A review of Resident 1's Minimum Data Set (MDS- federally mandated assessment tool), Cognitive Patterns, dated 12/22/25, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 9 out of 15 that indicated Resident 1 had moderate cognitive impairment. A review of Resident 1's "Nurses Progress Note," dated 1/31/26 at 10:09 a.m., indicated "...Resident room mate reported to the cna [Certified Nursing Assistant] that RP is physically abusing resident but when LN [Licensed Nurse] spoke with resident he just laughed over it and said "we were just fooling around" Another cna also said RP is violent because she witnessed the RP kicking the wall and resident bedside drawer when he discovered that resident drawer was cleaned and a pair of scissors he left in the drawer has been removed..." A review of Resident 1's "Nurses Progress Note," dated 2/2/26 at 3:32 p.m., indicated name of the form"... [Report of Suspected Dependent Adult/Elder Abuse-information by reporting party regarding suspected incident of abuse to notify regulatory agencies including The Department, the ombudsman, law enforcement] FILLED [sic] FOR ALLEGED VERBAL ABUSE ON 01/31/2026. IT HAS BEEN REPORTED [RP] IS ABUSIVE. UPON INTERVIEWING THE RESIDENT, [RESIDENT 1] STATED THAT HE HAS NEVER BEEN PHYSICAL, BUT HE DOES YELL AND HE CONSIDERS [RP] TO BE AN ANGRY PERSON... REPORT SENT OVER FOR CDPH [California Department of Health], OMBUDSMAN VIA FAX. REPORT CALLED IN TO LOCAL LAW ENFORCEMENT..." During an interview on 2/24/26 at 10:35 a.m. with Resident 1, Resident 1 stated his RP is his paid caregiver and comes into facility usually every other day and assists with correspondence, grooming, and transportation to appointments. Resident 1 stated his RP came in to give him a shave and the shaving cream was missing which made the RP angry. Resident 1 stated the RP began yelling and slammed the door really hard. When asked if the RP was ever abusive to him, Resident 1 stated the RP gets mad and uses profanity, which bothers him. During an interview on 2/24/26 at 11:02 a.m. with LN 1, LN 1 stated Resident 1 has a hired caregiver who comes in to provide grooming to Resident 1 and takes him out of the facility. LN 1 stated there was a report that the caregiver was verbally abusing to Resident 1. LN 1 stated Resident 1's paid caregiver talked aggressively to Resident 1 and was always angry. LN 1 stated she informed the Administrator (ADM) of the report of verbal abuse of Resident 1 by his caregiver. During a concurrent interview and record review on 2/24/26 at 1:22 p.m. with the ADM, the ADM acknowledged that incident with Resident 1 and his caregiver occurred on 1/31/26 as reported by his roommate and CNA. The ADM stated LN 1 did not report incident or complete the reporting form on 1/31/26 when reported to her because she did not see or hear the incident herself. The ADM stated she (ADM) was not aware of the incident until 2/2/26 and then the reporting was completed. The ADM acknowledged that the reporting document was not sent within the regulatory timeframe for abuse reporting. During an interview on 2/24/26 at 1:31 p.m. with CNA 3, CNA 3 stated Resident 1's caregiver comes in every day or every other day. CNA 3 stated on 1/31/26 she offered to shave Resident 1, but he stated his caregiver would do it. CNA 3 stated Resident 1's caregiver came in and became angry there was no razor in the nightstand drawer, started talking loudly, became aggressive kicking the closet door and the trash can. CNA 3 stated she was afraid the caregiver was losing control and afraid of what he might do. CNA 3 stated Resident 1 caregiver's behavior was potential abuse. CNA 3 stated the incident occurred on 1/31/26 and was reported to the nurse. CNA 3 stated it should have been reported the same day to The Department. CNA 3 stated, "Don't know why it was not done that day (1/31/26)." During an interview on 2/24/26 at 1:56 p.m. with CNA 4, CNA 4 stated Resident 1's roommate reported to him on 1/31/26 that Resident 1's caregiver was becoming verbally aggressive to Resident 1. CNA 4 stated he notified LN 1 of the situation. When asked what the policy is for abuse reporting, CNA 4 stated he would notify the nurse, and the nurse should report it the same day as the suspected abuse. CNA 4 stated he was not sure of the regulatory timeframes for abuse reporting. During a subsequent interview on 2/24/26 at 2:22 p.m. with LN 1, when LN 1 was asked why she did not complete and file the report on1/31/26 and send to The Department, LN 1 stated Resident 1 did not indicate he was being abused and the roommate who reported incident was not reliable. LN 1 stated she did document the incident in the chart in case it needed to be reported later. During a telephone interview on 2/25/26 at 9:13 a.m. with LN 3, LN 3 stated she filed the report on 2/2/26 for incident with Resident 1 based on Resident 1's progress note on 1/31/26. LN 3 stated she completed the report on 2/2/26 because LN 1 was off that day but did not have any first-hand knowledge of the incident. A review of the facility's Policy and Procedure (P&P), titled "Abuse Investigation and Reporting," revised 7/17, indicated "...All reports of resident abuse...mistreatment shall be promptly reported to local, state and federal agencies...and thoroughly investigated by facility management...All alleged violations involving abuse ... or mistreatment...will be reported...to the following persons or agencies...The State incensing/certification agency responsible for surveying licensing the facility...The Local/State Ombudsman... Law enforcement officials...An alleged violation of abuse...mistreatment...will be reported immediately, but not later than: ...Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury, or...Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resolved in serious bodily injury..." A review of the facilities P&P titled "Abuse Prohibition Policy and Procedure," dated 2/23/21, indicated "...HealthCare Centers prohibit abuse, mistreatment...and exploitation for all residents... Upon receiving information concerning a report of suspected or alleged abuse, mistreatment...the CED [Center Executive Director] or designee will perform the following...Report allegations involving abuse (physical, verbal, sexual, mental) not later than two (2) hours after allegation is made...Notify local law enforcement, Ombudsman, Licensing District Office..." Therefore, The Department determined the facility failed to report suspected abuse for one of three sampled residents (Resident 1) to The Department within the regulatory timeframe, when Resident 1's visitor/caregiver was reported as abusive on 1/31/26 to a mandated reporter and the incident was not reported until two days later on 2/2/26. This failure resulted in a delay of investigation of abuse which had the potential for abuse to continue causing increased emotional distress or mental anguish for Resident 1. This violation had a direct or immediate relationship to the health, safety, or security of Resident 1.