Health inspection·January 16, 2026

The following reflects the findings of the California Department of Public Health during the investigation of: Complaint #: 2696826 Event ID: 1DF2F1-H1 Representing the Department, Nurse Surveyor #49330. State Citation B was written. California Health and Safety Code - HSC § 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. (b) A failure to comply with the requirements of this section shall be a class "B" violation. § 483.12 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) The facility must- (1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; (2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. (3) Not employ or otherwise engage individuals who- (i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or (iii) Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. (4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. (b) The facility must develop and implement written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, (2) Establish policies and procedures to investigate any such allegations, and (3) Include training as required at paragraph § 483.95. (4) Establish coordination with the QAPI program required under § 483.75. (5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements. (i) Annually notifying covered individuals, as defined at section 1150B(a)(3) of the Act, of that individual's obligation to comply with the following reporting requirements. (A) Each covered individual shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from, the facility. (B) Each covered individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. (ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act. (iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act. (c) 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. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. On 12/19/25 at12:45 P.M., an unannounced visit was conducted at the facility to investigate a complaint regarding an allegation of abuse. The facility failed to report an allegation of sexual abuse for one of three sampled residents (Resident 1) to the California Department of Public Health (CDPH) within twenty-four (24) hours from the time the facility learned of the allegation. This failure had the potential for Resident 1 to experience continued abuse and negative psychosocial outcomes. During a record review on 12/19/25, the Admission Record indicated Resident 1 was admitted to the facility on 11/19/25 with diagnoses which included alcoholic cirrhosis of liver (severe scarring of the liver caused by alcohol abuse), major depressive disorder, anxiety disorder, and unspecified dementia. During a record review on 12/19/25, the Minimum Data Set (MDS-a federally mandated assessment tool) indicated Resident 1 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) of 9, which indicated Resident 1 had impaired cognition. During an interview with the Assistant Director of Nursing (ADON) on 12/19/25 at 12:45 P.M., the ADON stated on 12/18/25 around 1 P.M., the police arrived at the facility in response to a 911 call. The ADON stated Resident 1 called 911 to report that he had been abused by a staff member. The ADON stated she was present during the police's interview with Resident 1. The ADON stated during the interview, Resident 1 stated that a staff member, "...asked him, 'how are you honey' and touched his shoulder and touched his butt..." The ADON stated Resident 1 did not report this allegation to any staff member. During an interview with Licensed Nurse (LN) 1 on 12/19/25 at 1:30 P.M., LN 1 stated he was present during Resident 1's interview with the police officer. LN 1 stated, [Resident 1] told the cop his nurse was flirtatious with [Resident 1], [the nurse] was overly nice...[Resident 1] said he felt like it was sexual harassment." LN 1 stated Resident 1 identified Licensed Nurse (LN) 2 as the alleged perpetrator. LN 1 stated Resident 1's comments were an allegation of abuse. During an interview with the Director of Nursing (DON) on 12/19/25 at 2:02 P.M., the DON stated Resident 1 accused LN 1 of harassment and, "any type of harassment is abuse..." The DON acknowledged that the facility did not report the abuse allegation to the State Licensing Agency, the ombudsman, or the police department. The DON stated she did not initiate the investigation or report the incident because she was training the ADON to investigate allegations of abuse. The DON stated, "I wanted [the ADON] to train and take initiative over the incident..." The DON stated it was her expectation that any allegation of abuse was reported to the State Licensing Agency, the ombudsman and the police per regulation and facility policy. During an interview with Resident 1 on 12/19/25 at 3:22 P.M., Resident 1 stated, "About 12 days ago, one of the male nurses was flirtatious with me. It started with 'hey honey, how's it going?' I blew it off and [the flirtatious behavior] increased..." Resident 1 further stated, "[LN 1] stroked my face, and he put his fist in my [vulgar word for buttocks]..." Resident 1 stated he called the police but does not remember whether he told staff about LN 1's actions. During an interview with the Director of Operations (DO) on 12/19/25 at 3:31 P.M., the DO stated he was the designated abuse coordinator for the facility. The DO stated as abuse coordinator, his responsibility was to ensure all allegations of abuse were reported to the State Agency per policy. The DO acknowledged Resident 1's allegations were not reported to CDPH. During a record review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, revised September 2022, the policy indicated, "All reports of resident abuse...are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported...The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/state ombudsman; c. The resident's representative; d. Adult protective services...e. Law enforcement officials; f. The resident's attending physician; and g. The facility's medical director..."Immediately" is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury." In violation of the above cited standards, the facility failed to report an allegation of sexual abuse for one of three sampled residents (Resident 1) to the California Department of Public Health (CDPH) within twenty-four (24) hours from the time the facility learned of the allegation, which placed Resident 1 at risk for further abuse.