Health inspection·January 28, 2026

Code of Federal Regulations, Title 42, Section §483.12 483.12(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. California Health and Safety Code, 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. On 12/22/25, at 11 am, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate one (1) Complaint and one (1) Facility Reported Incident regarding abuse. The facility failed to ensure an allegation of employee-to-resident physical abuse was reported by the facility for one of three sampled residents (Resident 1) when on 11/17/25, the facility failed to report Resident 1's allegation of physical abuse by a Licensed Nurse to the state agency. This failure resulted in a delayed abuse investigation and had the potential to affect Resident 1's physical and psychosocial well-being. During an interview on 12/22/25 at 1 PM, in Resident 1's room, Resident 1 stated that a few weeks ago he had his cat food taken away and his arm twisted by Licensed Nurse (LN) 1 and that it was witnessed by a Certified Nursing Assistant (CNA). Resident 1 explained he called the police on 11/17/25 and made a police report because LN 1 got angry with him, grabbed and twisted his left arm hard enough to tear off a bandage on Resident 1's elbow while LN 1 took away Resident 1's bag of cat food. Resident 1 stated he bought cat food with his own money and liked to leave cat food for the stray cats on the patio outside of his room. Resident 1 further stated that in addition to the CNA witnessing the incident, he also told the Director of Nursing (DON) when she came into the room that he was physically hurt by LN 1. Resident 1 explained that he felt like, "I'm nothing and a nobody to them," and that he did not feel like the facility cared about him or his rights. Resident 1 further explained that he told the DON that he no longer wanted LN 1 to be his nurse. During an interview on 12/22/25 at 12:45 PM, LN 2 stated that if he observed or heard a report of an alleged abuse, he would report it immediately to his DON or Administrator (ADM). LN 2 explained the process for reporting any type of alleged abuse including resident to resident, or staff to resident, was to check the resident head to toe and make sure the resident was safe and not injured. LN 2 further explained he would then call the doctor to notify him, report the incident to the police, complete the required abuse reporting forms, notify the Ombudsman (an appointed official to advocate for residents and resident rights), the state agency (state agency responsible for investigating alleged abuse and other resident complaints) and document the incident and who he notified in the resident's medical record. LN 2 stated in addition, we would monitor the residents for 72 hours to make sure the residents felt safe. LN 2 stated it was important to report allegations so that it did not happen in the future and to keep the residents safe. LN 2 further stated this was standard abuse allegation reporting procedures for all staff with knowledge of an alleged abuse. During an interview on 12/22/25 at 1:54 PM, CNA 1 stated that on 11/17/25 she was outside in the hallway around 7:30 to 7:45 AM passing breakfast trays to other residents and only walked past Resident 1's room but did not go inside of the room. CNA 1 further stated she remembered that there was a problem with Resident 1 feeding stray cats and that Resident 1 looked upset and LN 1 was in Resident 1's room. CNA 1 explained when the police came and took the report, she was surprised she was listed as a witness because CNA 1 stated she did not witness anything and was not in the room during the time of the allegation. During a concurrent interview and record review on 12/23/25 at 8:55 AM, LN 1 stated that he could not recall the events on 11/17/25. Reviewed LN 1's progress note (a part of a patient's record, documenting their health status, treatment response, and changes during care to track progress, ensure accountability, and facilitate communication among healthcare providers) dated 11/17/25, indicated: "...[at] 0755 [AM] CNA and LN noted [Resident 1] feeding stray cats from inside the [Resident 1's] room. [LN 1] took the bag of cat food that was sitting on top of a chair in room. At this time the CNA were present...0800 [AM] DON made aware of this situation and DON walked to [Resident 1's] room...[Resident 1] stated "Your nurse there ([Resident 1 was pointing to the direction of myself [LN 1]) hurt me and twisted my left arm"...Cops arrived...0823 [AM]..." LN 1 was then able to recall the events on 11/17/25 and added that CNA 1 was inside Resident 1's room when the incident occurred and could confirm that LN 1 did not touch or hurt Resident 1. LN 1 stated the DON was aware of the accusation from Resident 1, and LN 1 talked to the police when they came to the facility on 11/17/25 to make the police report. LN 1 stated he did not call the police to make a report and clarified that Resident 1 called the police to report he was abused. LN 1 further stated it was important to report abuse allegations for patient's rights and safety and added the risk to the residents for unreported abuse allegations were ongoing or continued abuse. During a concurrent interview and record review on 12/22/25 at 3:21 PM, the DON confirmed she was aware of the allegation of abuse to Resident 1 on 11/17/25. The DON further stated that she did not report the allegation of abuse to the required agencies because the police officer told her Resident 1 recanted (took back) his story and the police officer would not be making a police report on the alleged abuse. When asked if the DON had confirmed this information with Resident 1, or if she made a progress note documenting this information, she stated, "no". The police report dated 11/17/25, report number 25-34636, was reviewed with the DON. The DON was made aware that a police report was completed and there was no mention of Resident 1 recanting his story in the police report. The police report also indicated the events were transcribed from the body camera worn by the officer at the time the police report was taken. When asked if the DON made any attempt to interview Resident 4, Resident 1's roommate, she stated, "no". The DON confirmed the facility did not investigate the allegation or complete the required notifications per their facility policy. During an interview on 12/22/25 at 4 PM, the Administrator (ADM) stated she was new to the facility and it was her expectation that all staff with knowledge of an alleged abuse report it immediately and make all the required notifications within two hours. The ADM added this allegation of abuse should have been reported to the police by the facility, to the state agency, the Ombudsman, and the facility should have completed their own investigation. The ADM stated the risk to the residents when alleged abuse was not reported could be emotional distress and the potential for abuse to continue. The ADM explained it was important for the residents to trust the facility staff, and for the residents to feel safe. Review of the facility policy and procedure titled, "Abuse, Neglect and Exploitation," undated, indicated, "...It is the policy of this facility to provided protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse...An immediate investigation is warranted when suspicion of abuse...or report of abuse, neglect or exploitation occur...Reporting of all alleged violations to the Administrator, state agency, adult protective services and all other required agencies...within specified time frames...Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse...Administrator will follow up with government agencies...to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies..." Therefore, the facility failed to ensure an allegation of employee-to-resident physical abuse was reported by the facility for one of three sampled residents (Resident 1) when on 11/17/25, the facility failed to report Resident 1's allegation of physical abuse by a Licensed Nurse to the state agency. This failure resulted in a delayed abuse investigation and had the potential to affect Resident 1's physical and psychosocial well-being. This violation had a direct or immediate relationship to the health, safety and or security of patients or residents.