Health inspection·August 26, 2025

The following reflects the findings of the California Department of Public Health during the investigation of Complaint: 2561079 abbreviated survey Event ID: 1D1148-H1. Representing the Department, Riz Ruiz, HFEN #40615 State Citation B was written. §483.12 - 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. §72523(a) - Patient Care Policies and Procedures. Written patient care policies and procedures shall be established and implemented to ensure that patient-related goals and facility objectives are achieved. On 7/16/25 at 10 A.M., an unannounced visit to the facility was conducted. Resident 1 reported that her credit card was missing from the facility and a report from the credit company indicated unauthorized charges on Resident 1's credit card. The facility failed to safeguard Resident 1 from financial exploitation (illegal use of another person's money) when certified nursing assistant (CNA) 2 used Resident 1's credit card without permission, which resulted in a total of $568.66 unauthorized charges on the resident's credit card. Resident 1 was admitted to the facility on 1/22/25, with diagnoses which included urinary tract infection (a condition in which bacteria invade and grow in the urinary tract), per the facility's Admission Record. On 7/16/25, a review of the minimum data set (MDS- an assessment tool), dated 4/25/25, indicated Resident 1's brief interview for mental status (BIMS - test the resident's cognition status) was 15 (13- 15 meant intact cognition). A review of the Interdisciplinary Team Care Conference (IDT -a group of healthcare professionals from various disciplines who collaborate to provide comprehensive patient care), dated 7/11/25, indicated, "...IDT met to discuss an incident involving alleged financial abuse. A report was received from the resident assigned resource counselor regarding an unusual charge on Resident 1's credit card. The resident had given her credit card to a few of the CNA's (certified nursing assistant) to get snacks from the vending machine..." On 7/16/25 at 10:50 A.M., an observation and an interview with Resident 1 was conducted in her room. Resident 1 was lying in her bed with the head of the bed elevated. Resident 1 stated she would give her credit card to a CNA to buy soda or snacks from the vending machine. Resident 1 stated she could not remember if her credit card was missing but a staff member found her credit card in the nightstand drawer. Resident 1 stated she could not remember the name or identify the staff member. On 7/16/25 at 11:05 A.M., an interview was conducted with CNA 1. CNA 1 stated Resident 1 would ask CNA 1 to get her soda or snacks from the vending machine, and Resident 1 would give her credit card to CNA 1. CNA 1 stated after buying snacks, she would return the credit card to Resident 1. On 7/16/25 at 11:26 A.M., an interview was conducted with the Social Service Director (SSD). The SSD stated on 6/23/25, Resident 1 came to her office and reported that her credit card was missing. The SSD and another staff member searched Resident 1's room and found her credit card in the nightstand drawer. The SSD stated, on 7/9/25, Resident 1 and the resident's resource counselor spoke to the SSD to discuss and review the list of unusual transactions received from the credit card company. The unusual transactions charged to Resident 1's card indicated: - 5/31/25 - Smoke Shop - $50.00 - 5/31/25 - Smoke Shop - $102.83 - 6/1/25 - Smoke Shop - $102.84 - 6/6/25 - Gasoline Station - $6.30 -6/6/25 - Smoke Shop - $97.43 -6//6/25 - Smoke Shop - $ 97.43 - 6/18/25 - Smoke Shop - $97.43 - 6/21/25 - Coffee Shop - $ 14.40 On 7/16/25 at 11:48 A.M., a telephone interview was conducted with CNA 2. CNA 2 stated she was assigned to Resident 1 and familiar with Resident 1's care. CNA 2 stated Resident 1 would give her credit card to CNA 2 to get snacks from the vending machine then return back the credit card to Resident 1 after buying the snacks. CNA 2 stated in the month of June 2025, she forgot to return back the credit card to Resident 1. CNA 2 stated she was off for two days and had Resident 1's credit card with her. CNA 2 further stated she did not inform the facility and Resident 1 that the credit card was in her possession. CNA 2 stated she might have accidentally used Resident 1's credit card for purchase. On 7/16/25 at 12:18 P.M., an interview and joint review of the CNA 2's employee file review was conducted with the Director of Staff Development (DSD). The DSD stated staff received training on theft and loss during orientation. The DSD could not find the signed acknowledgement form from CNA 2. On 7/16/25 at 12:45 P.M., an interview was conducted with the Administrator (ADM). The ADM stated the investigation started on 7/9/25 when Resident 1 and Resident 1's resource counselor reported unusual charges in Resident 1's credit card. The ADM stated staff should not have taken residents' credit cards. Staff should accompany residents if they needed snacks in the vending machine. The ADM stated the facility reimbursed Resident 1's credit card charges. The ADM stated both CNA 1 and CNA 2 were interviewed separately during their investigation process. The ADM stated both CNA1 and CNA 2 acknowledged they accepted Resident 1's credit card to buy snacks from the facility's vending machine and would return the credit card back to Resident 1. The ADM stated he was not aware of staff accepting credit cards from the residents to buy snacks from the facility's vending machine. In addition, the ADM stated during an interview with CNA 1, CNA 1 denied knowing the place called Grateful Head Glass. CNA 1 stated she only used Resident 1's credit card to buy snacks from the facility's vending machine. The ADM stated during interview with CNA 2, CNA 2 acknowledged that she knew the smoke shop that Resident 1's credit card was used at and stated that she had purchased items there before. On 7/29/25 at 3:08 P.M., a telephone interview with Resident 1's resource counselor was conducted. The resource counselor (RC) stated she was assisting Resident 1 with her finances and noticed the unusual charges in Resident 1 credit card. The RC stated Resident 1 and the RC, contacted the credit card company and obtained an itemized list of unauthorized transactions. The list of charges in Resident 1's credit card was reviewed. The RC stated Resident 1 did not leave the facility since admission. The RC also stated Resident 1 used her card for snacks at the facility's vending machine. The RC stated she discussed and reviewed the itemized list of unusual charges in Resident 1's credit card with the facility social worker. On 7/31/25 at 8:50 A.M., an interview and record review were conducted with the SSD. The SSD stated the copy of the itemized transaction in Resident 1's credit card was provided by Resident 1 and Resident 1's resource counselor. The SSD stated Resident 1 used her credit card for the vending machine. The SSD further stated Resident 1 had not left the facility since admission. On 7/31/25 at 9:10 A.M., an interview and review of the itemized list of transactions in her credit card was conducted with Resident 1. Resident 1 stated she did not know the Grateful Head Glass, the Arco, Starbucks charges in her card. Resident 1 stated she used her card for the vending machine for snacks. Resident 1 was upset about the unusual charges in her credit card. She stated she got a new credit card and kept in the social worker's office. A review of the facility's policy and procedure titled, Theft and Loss of Resident Personal Property, dated 7/16/13, indicated "... facility shall make reasonable efforts to protect the personal property of residents in a manner that will comply with regulatory requirements ..." In violation of the standards above, the facility failed to safeguard Resident 1's from financial exploitation (illegal use of another person's money) when certified nursing assistant (CNA) 2 used Resident 1's credit card without permission, which resulted in a total of $568.66 unauthorized charges on the resident's credit card. In addition, the facility failed to follow their policy and procedure and caused misappropriation of Resident 1's money. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.