Health inspection·February 2, 2026

F 0606 Not hire anyone with a finding of abuse, neglect, exploitation, or theft. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to implement its abuse prevention policy and procedure to not employ or continue to employ anyone found guilty of abuse when: Facility employed one Certified Nursing Assistant (CNA 1) who had a finding of patient abuse record on background screening report conducted prior to employment. Facility did not check information from previous and/or current employers and make reasonable efforts to uncover information about any past criminal prosecutions for CNA 1 prior to employment. Finding is defined as a determination made by the state that validates allegation, mistreatment of residents, or misappropriation of their property. This failure had the potential to place residents at risk for emotional distress, mistreatment, or abuse. During a review of Resident 1's progress note, titled SBAR, dated 1/20/26, the SBAR (a communication tool used by licensed nurses to document residents' condition).indicated Resident 1 reported that CNA 1 verbally and physically abused Resident 1. SBAR indicated Resident 1 appeared anxious, intimidated, and uncomfortable with care. During a concurrent observation and interview on 1/26/26, at 10:15 a.m., with Resident 1, Resident 1 stated he asked CNA 1 to help with his clothes and drinking water. Resident 1 stated CNA 1 told him to stand up and help himself. Resident 1 stated CNA 1 spilled water on his wheelchair and damaged items in his wallet. Resident 1 was upset and anxious when he recited what happened with CNA 1. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems), dated 9/10/25, the MDS indicated Resident 1's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) score was 15 and indicated intact cognition. The MDS indicated Resident 1 had clear speech, made self understood and understood others. MDS indicated Resident 1 had diagnoses that included paraplegia (partial or complete paralysis of the lower half of the body, including both legs and sometimes the abdomen). During a telephone interview on 1/26/26, at 11:02 p.m., with CNA 1, CNA 1 stated Resident 1 was upset that his roommate wore his clothes and screamed. CNA 1 stated while trying to move Resident 1's bedside table to the side, a bottle of hot sauce and water slid from the table, broke and slipped on the floor. During a concurrent interview and record review on 1/26/26, at 11:26 a.m., with Director of Nursing (DON), CNA 1's Employee File (EF) was reviewed. The EF indicated facility employed CNA 1 on 2/17/22. Further review of CNA 1's EF indicated the background screening report (BGSR) for employment, dated 2/15/22, indicated CNA 1 had a finding in state nurse aide registry concerning abuse of patient. CNA1's BGSR indicated CNA1 was on the Office of Inspector General (OIG)/Medical exclusion and State Board list. (Background screening for employment is the process of verifying a job candidate's educational, professional, and personal history to assess their qualifications, safety, and integrity). Further review of EF indicated facility did not check references for CNA 1 from previous and/or current employers and make reasonable efforts to uncover information about any past criminal prosecutions prior to employment. DON Residents Affected - Some Page 1 of 2 056359 056359 02/02/2026 San Pablo Healthcare & Wellness Center 13328 San Pablo Avenue San Pablo, CA 94806

F 0606 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated there were no reference checks completed for CNA 1 on file. DON stated she had checked with payroll department and could not provide documentation of CNA 1's reference checks. During a concurrent interview and record review on 1/26/26, at 12:10 p.m., with the Administrator (Admin) and Director of Nursing (DON), CNA1's BGSR dated 2/15/22 was reviewed. The BGSR indicated, CNA 1 had a finding of Patient Abuse on record. Admin stated he was not aware of CNA 1's BGSR finding of patient abuse and was not involved in the hiring decision. Admin said facility does not hire nursing staff with patient abuse findings. During a review of the facility's policy and procedure (P&P) titled, Abuse Prevention and Management, dated 2022, the P&P indicated, a. The facility will screen potential employees for history of abuse, neglect, or mistreating residents, including attempting to obtain information from previous employers and/or current employers, and checking with the appropriate licensing boards and registries.b. The facility does not knowingly employ or continue to employ anyone found guilty of abuse, neglect, exploitation, . 056359 Page 2 of 2