Other·April 3, 2026

The following reflects the findings of the California Department of Public Health during the investigation of: Complaint #: 2798878 and 2797525 Event ID: 1F2EB3 State Citation B was written. §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(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. 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. (c) For purposes of this section, "abuse" shall mean any of the conduct described in subdivisions (a) and (b) of Section 15610.07 of the Welfare and Institutions Code. On 3/6/26, an unannounced visit was conducted at the facility to investigate a Complaint and a Facility Reported Incident regarding an allegation of Resident 1 being slapped in the face by staff at the skilled nursing facility. The facility failed to report an allegation of abuse to the California Department of Public Health (CDPH) within 2 hours for one of seven sampled residents (Resident 1). Based on observations, interviews, and record review the facility failed to report the alleged abuse of one (Resident 1) of seven sampled residents to the California Department of Public Health (CDPH) within two hours of the initial abuse allegation. This failure had the potential for further abuse to Resident 1. Findings: Record review of Resident 1's Admission Record indicated Resident 1 was admitted on 2/03/24 with diagnoses which included: Anxiety Disorder (excessive fear or worry that interferes with daily life) and need for assistance with personal care. Record review of Behavior Note by LN 1 dated 3/4/26 at 11:13 P.M., indicated "Resident 1 made threatening verbal statement toward CNA during care and stated, "You are not doing the right thing, and I will report you." Resident noted speaking in raised voice and appearing agitated...Supervisor notified." Record review of SOC 341 (a reporting form used by the facility to report allegations of abuse to California Department of Public Health (CDPH) indicated it was sent on 3/6/26 at 3:59 P.M. Review of facility policy titled "Abuse-Reporting & Investigations" dated March 2018, indicated "...V. Notification of Outside Agencies of Allegation of Abuse with No Serious Bodily Injury: A. The Administrator or designated representative will notify within two (2) hours notify by telephone, CDPH..." On 3/6/26 at 2:45 P.M., an observation and interview was conducted with Resident 1. Spanish translation was done by the Admissions Director (AD). Resident 1 was resting in her bed and observed to have approximately one-inch-long imitation fingernails. Resident 1 stated that on 3/4/26 in the evening, CNA 1 was giving her a bed bath and she (Resident 1) stated she turned to tell CNA 1 not to scrub her "glutes" when CNA 1 raised her hand and tried to slap her. Resident 1 stated she put up her hand to protect her face and the imitation nail on her right pinky broke. Resident 1 stated she reported the incident to License Nurse 1 (LN 1) that night (3/4/26) at about 10 P.M. Resident 1 stated she talked with the Social Services Assistant (SSA) on 3/5/26 at 4 P.M. about the incident. Resident 1 stated that the Administrator (ADM) came by to see her on 3/6/26 at about 2:40 P.M. to talk with her about the incident. On 3/6/26 at 3 P.M., an interview with the Social Services Assistant (SSA) was conducted. The SSA stated that on 3/5/26 at 4 P.M., she overheard Resident 1 talking with another staff member about the incident. Resident 1 stated that CNA 1 broke her nail during a bed bath. The SSA stated that Resident 1 alleged that CNA 1 was not following her instruction of how to properly clean her. The SSA stated that Resident 1 alleged she raised her hand and CNA 1 hit her and broke her nail. The SSA stated that the ADM was called on 3/5/26 at 4 P.M. to report the alleged abuse. On 3/6/26 at 5 P.M. an interview with the ADM was conducted. The ADM stated she was told about the incident after the incident happened on 3/4/26 at 11 P.M. by LN 1 and on 3/5/26 at about 4 P.M. by the SSA. The ADM stated she did not report to CDPH the alleged abuse that was reported to her on 3/4/26 until 3/6/26. The ADM stated she reported via SOC 341 on 3/6/26 to CDPH. On 3/19/26 at 11:45 A.M., an interview with the ADM was conducted. The ADM stated that the expectation for reporting alleged abuse was to report any alleged abuse to CDPH within two hours of the allegation being made. The ADM stated the importance of reporting within two hours of allegation was to protect residents from abuse and compliance with state and federal regulations.