Health inspection·January 21, 2026

The following reflects the findings of the California Department of Public Health during the investigation of: Facility Reported incident (FRI) CA 2667593, 2668557, and 2668605. Representing the Department, HFEN 51452. State Citation A was written. F- 600 42 C.F.R. § 483.12(a)(1) 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. (a) (1): The facility must-Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; F-610 42 C.F. R. §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. 22 CCR §72315 (b). Nursing Service - Patient Care (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. 22 CCR § 72523 (a). (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 11/26/25 at 10:19 A.M., an onsite investigation was conducted to investigate three Facility Reported Incidents (FRIs) alleging certified nursing assistant (CNA) 4 inappropriately touched Residents 1, 2, and 3. It was determined the facility failed to: 1. Ensure Resident 1, 2, and 3 were free from sexual abuse when: * Resident 1 stated CNA 4 fondled her clitoris and inserted his fingers in her vagina during care on 11/11/25. * Resident 2 stated CNA 4 "massaged" her vagina during a brief change sometime in July 2025. * Resident 3 stated CNA 4 inserted his fingers into her vagina during brief changes. * The facility hired CNA 4 with reference checks that reflected negative past employment performance. 2. Thoroughly investigate sexual abuse in the facility after conducting three investigations when: * The facility's investigation into the allegations against CNA 4 wrongly indicated the CNA had only favorable pre-employment references when this was not correct. * The facility failed to ask clarifying questions regarding sexual abuse during the course of their investigations to fully understand the residents' allegations. * The facility did not implement the facility's undated policy titled Administration related to abuse investigations. As a result, Residents 1, 2, and 3 experienced psychosocial harm (damage to a person's mental, emotional, and social well-being that was caused by their environment or experiences), stating the incidents with CNA 4 made them feel angry, humiliated, embarrassed, ashamed, and worried. The first reported incident (Resident 1): A review of Resident 1's Admission Record indicated the resident was admitted to the facility on 11/8/25 with diagnoses that included constipation, difficulty walking, and need for assistance with personal care. A review of Resident 1's Minimum Data Set Assessment (MDS, a comprehensive assessment tool) dated 11/28/25, indicated the resident's BIMS (Brief Interview for Mental Status) was 15 out of 15, indicating the resident was cognitively intact (no memory, focus, or judgment issues). A review of Resident 1's History and Physical dated 11/10/25 indicated the resident had capacity to understand and make decisions. A review of Resident 1's facility investigative summary dated 11/16/25, indicated, "...According to [Resident 1], during the NOC [night] shift on 11/11/25... [Resident 1] had a large soft stool that needed to be cleaned. The CNA came in, introduced himself as [CNA 4] ... and explained that he would change the brief...felt as if something brushed against her vaginal area." On 12/9/25 at 11:13 A.M., an interview was conducted with Resident 1. Resident 1 was asked about the allegation which the resident reported to the facility on 11/12/25. The resident stated she told a nurse about her abdominal pain caused by her constipation in the early morning of 11/12/25. Resident 1 stated CNA 4 came into her room and told her he could help with her constipation around 3 A.M. The resident stated CNA 4 then removed the front part of her brief and she felt his fingers rubbing against her clitoris. The resident then stated she felt CNA 4's fingers going into her vagina. Resident 1 stated when CNA 4 rubbed her clitoris and inserted his fingers into her vagina, it felt sexual in nature and was uncomfortable. Resident 1 stated she felt humiliated and ashamed, and she was glad CNA 4 no longer worked at the facility. The resident stated she reported this incident to her husband and the facility later that day. Resident 1 stated she reported the incident because it felt wrong that CNA 4 was taking advantage of people like her sexually. The resident remembered and verbalized CNA 4's name and stated she was worried if there were other residents who had been abused by CNA 4. A review of Resident 1's Care Plan developed on 11/12/25, indicated, the resident requested to have only female CNA or a female CNA to be present if a male CNA was to give her care. The second reported incident (Resident 2): A review of Resident 2's Admission Record indicated the resident was admitted to the facility on 1/14/25. A review of Resident 2's MDS assessment dated 10/7/25, indicated the resident's BIMS was 15 out of 15. A review of Resident 2's History and Physical dated 9/30/25, indicated the resident had capacity to understand and make decisions. A review of Resident 2's facility investigative summary dated 11/17/25, indicated, "...On 11/13/25 at approximately 2100pm [9 P.M.], a report was received... [Resident 2] alleged that a male staff touched her inappropriately while...changing her brief... [Resident 2] heard the alleged situation of inappropriate behavior with another resident in the building...." On 12/9/25 at 12 P.M., an interview was conducted with Resident 2. Resident 2 was asked about the incident with CNA 4 that she had reported to a CNA on 11/13/25. Resident 2 stated when the incident occurred, CNA 4 had changed her soiled brief. The resident stated CNA 4 told her that he was going to give her a massage which would make her feel better and help her go to sleep. Resident 2 stated CNA 4 then started massaging her vagina where "he should not be rubbing." Resident 2 stated CNA 4 rubbed her vagina outside and inside, then she felt his hand starting to go into her vagina. Resident 2 stated she realized what was happening and told CNA 4, "It better be the end of it. Never again do I want a massage," at which point CNA 4 stopped. Resident 2 stated CNA 4's actions made her feel very uncomfortable because "no doubt in my mind" that the brief change by CNA 4 was different from a normal one. Resident 2 stated the incident made her feel angry and she felt CNA 4 took advantage of her. A review of CNA 4's employee file indicated that there was a grievance filed against CNA 4 by Resident 2 on 7/21/25. The grievance indicated the CNA was "a little too friendly" and "[Resident 2] just wa [sic] the CNA to do her brief change and so she can go to sleep" and Resident 2 requested to not have CNA 4 be assigned to her. The grievance did not mention a sexual touch by CNA 4. On 12/11/25 at 10:04 A.M., a follow up interview was conducted with Resident 2. Resident 2 was asked about the grievance she filed against CNA 4 on 7/21/25. Resident 2 was asked when the incident with CNA 4 had occurred. The resident stated it happened a few days before the grievance was filed (on 7/21/25). Resident 2 stated she did not include the "sexual abuse encounter" in the grievance. Resident 2 stated she regretted not including the sexual abuse committed by CNA 4 in the grievance because other residents could have been victimized by him, too. The resident stated she was especially worried about the non-verbal, vulnerable residents who could not speak up about abuse. Resident 2 stated when CNA 4 massaged her vagina, it was an unpleasant experience, and it felt sexual in nature. Resident 2 stated after this incident with CNA 4 on 7/21/25, "I was on the edge as to who is going to be the CNA at night, worried that he was going to be my CNA again." Resident 2 stated CNA 4 changed her brief again one night in October. Resident 2 stated CNA 4 did not massage or insert his fingers into her vagina that time because she recognized him when he entered her room and told him, "No massages, no nothing, just a change." A review of the CNA assignment for July through October 2025, indicated CNA 4 had provided care to Resident 2 on 7/14/25 and 10/21/25 during the NOC shift (11P.M. to 7A.M.). A review of Resident 2's therapy note dated 11/14/25, indicated, the therapist and Resident 2 discussed the "recent Stressful incident with male staff" and Resident 2 expressed feeling "Worry" during the therapy. A review of Resident 2's Care Plan Intervention initiated on 10/24/25, indicated Resident 2 refused certain CNAs without providing specific reasons. The third reported incident (Resident 3): A review of Resident 3's Admission Record indicated the resident was admitted to the facility on 6/12/24 with diagnoses which included a need for assistance with personal care. A review of Resident 3's MDS assessment dated 9/16/25, indicated the resident's BIMS was 15 out of 15. A review of Resident 3's History and Physical dated 12/7/24, indicated the resident had capacity to understand and make decisions. A review of Resident 3's facility investigative summary dated 11/17/25, indicated, "...On 11/13/25 at approximately 18:45pm [6:45 P.M.], a report was received... [Resident 3] told the psychologist (a mental health professional who helps people understand their thoughts, feelings, and behaviors to manage life's challenges) that she heard the alleged situation of inappropriate behavior with another resident in the building...prompted her to share her own allegation...some months ago...After cleaning her...the CNA applied barrier cream...around the private area...that made her feel it was inappropriate...." On 12/9/25 at 11:34 A.M., an interview was conducted with Resident 3. Resident 3 stated that CNA 4 touched her inappropriately on multiple days but could not remember the exact dates or times of the incidents. Resident 3 stated she remembered one incident when CNA 4 inserted a finger into her vagina after a brief change. Resident 3 stated this was a few months ago. Resident 3 stated she did not want her brief changed by CNA 4 anymore after the incident and would feel relieved when someone else was assigned as her CNA. Resident 3 stated when CNA 4 was alone with her, he touched her inappropriately. Resident 3 stated when he had another staff member with him, he would not touch her in the "wrong way." Resident 3 stated she felt having CNA 4's fingers around or inside her vagina was "sexual and wrong." Resident 3 stated she did not report the incident right away because she thought she was "going crazy" and questioned if the incident really happened. Resident 3 then stated she felt she was old enough to differentiate what was sexual and what was not. The resident stated she told herself that reporting was the right thing to do because CNA 4 should not be touching her the way he did. Resident 3 stated she was concerned there were other victims. A review of Resident 3's Psychiatry (medical doctors treating mental health) Progress Note dated 9/10/25, indicated, Resident 3 denied sleep disturbance, depressive symptoms, and anxiety symptoms. A review of Resident 3's therapy Progress Note dated 11/13/25, indicated, Resident 3 discussed about a "recent negative encounter" and Resident 3 expressed having anxiety, depressed mood/grief, fatigue, and sleep disturbance. The Progress Note indicated Resident 3 reported a safety concern. A review of Resident 3's therapy Progress Note dated 11/14/25, indicated, Resident 3 discussed thoughts and feelings surrounding "stressful incident" and expressed having anxiety, depressed mood/grief, helplessness, and worry. A review of Resident 3's therapy Progress Note dated 11/17/25, indicated, Resident 3 discussed about "anxiety regarding recent decision" and expressed having anxiety, fatigue, negative self-talk, and sleep disturbance. A review of CNA 4's employee file indicated CNA 4 was hired on 1/28/25. There were two printed reference checks titled [Facility name] - Confidential Reference Check both dated 1/24/25 in CNA 4's employee file. The reference checks reflected CNA 4's past employment. The reference checks indicated the CNA "...became lazy in PT [patient] care, unreliable...over confident [sic]...became inconsistent" and "...caught sleeping on the job." Both previous employers indicated they would not rehire CNA 4. A review of Resident 1, 2, and 3's facility investigative summaries dated 11/16/25 and 11/17/25 indicated that the facility's review of CNA 4's three pre-employment references revealed "only positives [sic] things to say about the employee." On 12/11/25 at 3:25 P.M., an interview was conducted with the director of nursing (DON) and administrator (ADM). The DON stated the facility did not have a policy regarding reference checks. The DON stated recruiters at HR (Human Resources) were responsible for the initial reference checks. The ADM further stated the facility did not have a paper written statement by CNA 4 regarding the three sexual abuse allegations. On 12/11/25 at 4:47 P.M., an interview and record review was conducted with the Director of Staff Development (DSD). The DSD reviewed the facility's undated policy titled Administration and stated it was the material she used to educate the staff regarding abuse and abuse related topics. The DSD stated it was considered sexual abuse for a staff to rub and insert their fingers in a resident's vagina. The DSD stated CNA 4 received an in-service regarding proper communication after Resident 2 filed the grievance on 7/21/25. The DSD stated she had no other grievance filed against CNA 4. The DSD reviewed CNA 4's pre-employment references dated 1/24/25 and stated she would hesitate to hire someone with such negative references. The DSD stated CNA 4 was not given any abuse in-services after the first sexual abuse report made by Resident 1 on 11/12/25 because he was sent home and suspended during the facility investigations for the three allegations and then he resigned effective 11/25/25. A review of CNA 4's Employee Resignation Form dated 11/25/25, indicated CNA 4 resigned from his CNA position at the facility effective 11/25/25. On 12/11/25 at 4:52 P.M., a concurrent interview and record review was conducted with the ADM. The ADM stated that he reached out to CNA 4 via text on his phone as he was previously asked for CNA 4's phone number. The ADM presented the text for review and stated CNA 4 had declined a phone interview with the surveyor. On 12/11/25 at 5:41 P.M., an interview and record review was conducted with the ADM and the DON. The DON stated she recognized there was a "red flag" when she received the report from Resident 1 on 11/12/25. The DON stated she would have had CNA 4 terminated when the third sexual allegation was reported to her, because of the magnitude of the allegations. The DON also stated if CNA 4 had not quit, he would have been terminated for the safety of the other residents. The DON and ADM reviewed CNA 4's two printed reference checks dated 1/24/25. The ADM was asked about the discrepancies between the three favorable reference checks mentioned in the facility's investigative summary report for Resident 1, 2, and 3 and the two unfavorable references contained in the CNA's personnel file. The ADM and DON reviewed the two unfavorable references dated 1/24/25 and stated they had never seen them. The DON stated that reviewing references was a part of onboarding process and if she had seen those reviews she would not have hired him. The ADM stated he called the HR recruiter and received positive comments on CNA 4's references