Health inspection·January 7, 2026

F 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect one resident (Resident 1) of five sampled residents from misappropriation (the unauthorized use of another person's property or money without permission) of property when Staff 1 made unauthorized charges to Resident 1's credit card.This failure resulted in Staff 1 misappropriating $27,571.50 from Resident 1's bank account which would leave a reasonable person upset, disturbed and financially injured. Findings:A review of Resident 1's admission record indicated she was admitted on [DATE] with diagnosis which included major depressive disorder (a serious mood disorder which causes persistent sadness, hopelessness, and loss of interest which significantly impairs daily life), mild neurocognitive disorder with behavioral disturbance (a condition that impairs mental functions like memory, thinking, and reasoning due to brain damage from various causes), anxiety disorder (a mental condition characterized by excessive fear which can impair daily life), and the need for assistance with personal care. A review of Resident 1's Minimum Data Set (MDS- a federally mandated assessment tool), dated 10/27/25, indicated Resident 1 had severe memory impairment.A review of an undated facility document titled Alleged Abuse written by the Director of Nursing (DON) indicated, Was reported to this writer by the Ombudsman [an independent advocate who investigates and helps to resolve resident complaints] that she received a call from [Resident 1's] bank that [Resident 1's] bank card is connected to a phone number of an employee [Staff 1] charging the card of [Resident 1] in greater than $4000.00 in. transactions. This record further indicates, Resident 1's bank card was connected to [the] phone number [Staff 1]. This document also indicated Resident 1 was only oriented to herself (only knew her identity but was confused about the current date, time, where she was or what was going on) and that the facility notified the local police of the alleged abuse on 12/19/25.A review of the police report dated 12/19/25 indicated, On 12/19/25, [DON] called [the police department] on behalf of. [Resident 1]. Between 1/15/25 to 11/1/25, [Resident 1's] debit card had been fraudulently used by an employee of the care facility [Staff 1]. As of the time of this report, [the bank] has accounted for approximately $27,571.49 missing from [Resident 1's] account.In an interview on 1/7/26 at 12:45 p.m. with the Administrator (ADM) and DON, the ADM confirmed Staff 1's phone number was connected to the charges on Resident 1's credit card. The ADM further confirmed the facility had separated their employment agreement with Staff 1 based on this incident. In an interview on 1/7/26 at 4:02 p.m., Bank Employee (BE) stated a joint account holder of Resident 1's account had contacted the bank to find out why someone had been taking money from Resident 1's account. The BE stated their investigation had indicated the fraud had been going on for about a year and exceeded $4,000.00.In an interview on 1/9/26 at 1:38 p.m. Police Officer (Officer 1) stated Staff 1 was definitely involved in the misappropriation of Resident 1's property. Officer 1 further stated the charges currently amount to $27,571.49 and the investigation was ongoing. In an interview on 1/15/26 at 11:57 a.m., the ADM stated if a large amount of money was stolen from him, he would be very disturbed Residents Affected - Few Page 1 of 3 056430 056430 01/07/2026 Northgate Postacute Care 40 Professional Center Parkway San Rafael, CA 94903

F 0602 Level of Harm - Actual harm and would want someone to be held accountable. The ADM further stated any reasonable person would feel the same. A review of the facility's policy titled, Abuse and Neglect Prohibition policy, revised June 2022 indicated, It is the facility's policy to prohibit abuse, mistreatment, neglect, involuntary seclusion and misappropriation of property for all residents. Residents Affected - Few 056430 Page 2 of 3 056430 01/07/2026 Northgate Postacute Care 40 Professional Center Parkway San Rafael, CA 94903

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to conduct a thorough background screening for one employee (Staff 1) when Staff 1's criminal background check results indicated it was incomplete. This failure decreased the facility's potential to protect and prevent abuse to their resident population.Findings:A review of Staff 1's personnel record on 1/7/26 indicated Staff 1's criminal background check (a screening process to investigate an individual's criminal history revealing details like felony and misdemeanor convictions, arrests, pending court cases, and active warrants) indicated the 7-year county review need attention. The background check notes indicated, Service closed as incomplete. attempted to obtain information from the applicant/client however a response with the needed information was not received.In an interview on 1/7/26 at 12:45 p.m. with the Administrator (Admin), the Admin stated, he would not have moved the applicant forward until the matter had been satisfied. The Admin further confirmed there was no documentation in Staff 1's file that included completion of this background check.A review of the facility's policy titled Abuse and Neglect Prohibition Policy, dated June 2022, indicated, It is the facility's policy to prohibit abuse. and misappropriation of property for all residents through the following: screening of potential hires .The facility will screen potential employees for a history of abuse, neglect or mistreating residents .The facility will not employ individuals who .Have been found guilty by a court of law of abusing, neglecting, or mistreating others .A review of the facility's policy titled, Background Screening Investigations, dated January 2018, indicted, Our facility conducts employment background screening checks, references checks and criminal investigation checks on all applicants for positions with direct access to residents .Should the background investigation disclose any misrepresentation on the application form or information indicating that the individual has been convicted of abuse, neglect, mistreatment of individuals, and/or misappropriation of property, the applicant is not employed or contracted. Residents Affected - Few 056430 Page 3 of 3