Health inspection·January 5, 2026

Code of Federal Regulations, Title 42, Section 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. Code of Federal Regulations, Title 42, Section 483.25. Quality of Care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices, including but not limited to the following: California Code Regulations, Title 22, Section 72527. Patients' Rights (a)Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (10) To be free from mental and physical abuse. California Code of Regulations, Title 22, Section 72311. Nursing Service – General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time-limited. (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. California Code of Regulations, Title 22, Section 72315. 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. California Code of Regulations, Title 22, Section 72523. Patient Care Policies and Procedures. (a)Written patient care policies and procedures shall be established and implemented to ensure that patient-related goals and facility objectives are achieved. On 9/25/25 at 11 am, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to conduct an investigate on three Facility Reported Incidents regarding abuse. The facility failed to provide adequate one-to- one monitoring (one staff member monitors one resident) to detect, prevent and de-escalate the Resident to Resident altercation incident when Resident 1 with a history of multiple resident-to-resident altercations, on one-to-one monitoring, made racial slurs and pushed Resident 6 on 9/18/25 This failure resulted in Resident 6 falling from his wheelchair. A review of Resident 1' s medical record titled,” ADMISSION RECORD”, indicated Resident 1 was admitted to the facility with diagnoses including paranoid schizophrenia (a mental health condition that is characterized hearing and seeing things that are not real), insomnia (persistent problems falling and staying asleep), major depression disorder ( a mental health disorder characterized by depressed mood or loss of interest in activities), and anxiety disorder (a mental health conditions characterized by excessive and persistent worry, fear, and nervousness). A review of Resident 1’s medical record titled, “Order Summary Report,” dated 9/24/25, indicated there was an active physician's order for one-on-one supervision (one staff member monitors one resident) 24 hours a day that was initiated on 6/8/25. There was also an active physician's order for monitoring episodes of aggressive behavior as evidenced by (AEB) striking out at others and was initiated on 9/10/25. A review of Resident 1’s medical record titled, “Interdisciplinary Care Conference – V5”, dated 9/19/25 indicated, “…On 9/18/25, it was reported that this resident [Resident 1] was involved in an altercation… [Resident 1] struck at [Resident 6]. [Resident 6] attempted striking back. Residents were separated immediately and assessed for injuries…Recommendations…72 hour monitoring – Q [every] 30 min safety checks…” A review of Resident 1’s medical record titled, “Progress Notes”, dated 9/18/2025 at 11:30 AM, indicated, “…per observer or witnesses [Resident 1] was verbally aggressive to [Resident 6] and contact was made but was separated by staff…” A review of Resident 1’s medical record titled, “Care Plan Report,” indicated the following: -6/28/22, “…Interventions…Monitor for mood and/or behavior changes or symptoms, assist in finding alternative interventions to aid resident’s [Resident 1] adjustment and understanding of need…maintain a safe environment with minimal stimulation…” -11/02/24, “Goal…Promote respectful interactions with peers and staff…Interventions… Educate the resident on the importance of non-violent communication and conflict resolution…Implement regular observations to assess behavior and provide immediate feedback…” -6/9/25, “…Focus…Resident [Resident 1] with potential/risk to exhibit psycho-social distress related to the following: 1. Resident served in Vietnam war. 2. Hx [history] of Homelessness…4. Dx [diagnosis] of schizophrenia and hx of stroke [a brain injury related to an event where oxygen to the brain is blocked]. 5. Physical Aggression triggered by paranoia r/t [related to] name calling, staring, being within close proximity with another person. (Res [resident]-to-Res Altercations:) - 1/24/2025 – 1/29/2025 – 2/26/2025 – 3/5/2025 – 3/10/2025 – 3/19/2025 – 3/24/25 – 4/17/2025 – 4/23/2025 – 5/9/2025 – 6/7/2025…Goal…Resident [Resident 1] will reduce or decrease episodes of PTSD [Post-traumatic stress disorder, a mental health condition that’s caused by an extremely stressful or terrifying event] triggered by altercations…Interventions…Resident to have 1:1 [one staff supervised one resident] staff support as indicated… Resident [Resident 1] will be supported in participating in restorative conversations, as appropriate…” -8/21/25, “…Goal…Resident [Resident 1] will have no decline in psychosocial well-being…resident [Resident 1] will have no episodes of resident-to-resident altercations…Interventions…. continue 1:1 supervision…” A review of Resident 6' s medical record titled,” ADMISSION RECORD”, indicated Resident 6 was admitted to the facility with diagnoses including schizophrenia (a chronic mental health condition characterized by a combination of symptoms that significantly impair a person's thoughts, perceptions, and behaviors), muscle weakness, major depression disorder, and anxiety disorder. A review of Resident 6’s medical record titled, “Interdisciplinary Care Conference – V5”, dated 9/19/25, indicated, “…On 9/18/25, Resident to resident altercation contributed to witnessed fall.…” A review of Resident 6’s medical record titled, “SBAR [Situation, Background, Assessment, and Recommendation] Communication Form”, dated 9/18/2025 at 12:45 PM, indicated, “…APPEARANCE... [Resident 1] began making racial slurs to [Resident 6] [Resident 6] then grabbed [Resident 1] by the collar of his shirt and began cursing. [Resident 1] was able to wheel self backwards with the help of his nurse aid. [Resident 6] then fell forward onto his hands and knees…” A review of Resident 6’s medical record titled, “Care Plan Report,” indicated the following: -4/24/25, “…Goal…Resident will demonstrate a reduction in episodes of aggression/restlessness…Interventions…Monitor and document behaviors …maintain consistent routines to minimize confusion and anxiety…” -9/08/25, “Goals…resident will have no falls …” During a concurrent observation and interview on 9/24/25 at 11:00 AM, Resident 1 was observed in his bed and stated he did not like Resident 6 and Resident 6 made him mad. Resident 1 stated he pushed Resident 6 and Resident 6 fell. Resident 1 stated he did not like loud sounds and Resident 6 was too loud when Resident 6 talked to God. Resident 1 stated Resident 6 slapped his chest and said derogatory (bad) words to Resident 1. Resident 1 stated at the time of the incident there was no staff providing one-on -one care (a personalized care model where a single caregiver provides their full and undivided attention to one individual) to him. During an observation and concurrent interview on 9/24/25 at 11:22 AM, Certified Nursing Assistant (CNA) 1 stated she was providing one-on-one care to Resident 1 because he was aggressive towards other residents. CNA 1 stated in the beginning of 9/25, she saw Resident 1 get agitated and speak to himself when Resident 1 saw other residents pass by his room. CNA 1 stated when she was sitting with Resident 1 outside his room, she heard Resident 1 say derogatory words to himself and she had redirected Resident 1 back to his room. During an interview on 9/24/25 at 11:36 AM, Licensed Nurse (LN) 1 stated Resident 6 had yelled at other residents in the past. LN 1 stated Resident 6 was sent to the hospital on 9/23/25 for yelling and having aggressive behavior towards a CNA and other residents. During an interview on 9/24/25 at 11:47 AM, Resident 2 stated he had heard Resident 1 yell and Resident 1 said derogatory words to Resident 6. Resident 2 stated that in the past Resident 1 had come into his room and punched him and, on 9/2/25, Resident 1 had yelled and used derogatory words towards him. Resident 2 stated he was worried Resident 1 would hurt him again. Resident 2 stated he would not like anyone to hurt his face because the injury would cause him to be in pain. During an interview on 9/24/25 at 12:36 PM, CNA 2 stated Resident 1 had told her that he did not like black people. CNA 2 stated when she provided one-on-one care to Resident 1, she witnessed Resident 1 show his middle finger and say derogatory words to other residents. During an interview and concurrent record review on 9/24/25 at 1:19 PM, LN 2 stated Resident 1 had been on one-on-one care since 6/8/25. LN 2 stated Resident 6 did not yell at anyone unless he was provoked. During an interview on 9/25/25 at 11:16 AM, Admissions Assistant (AA) stated the incident between Resident 1 and Resident 6 happened in the facility's lobby on 9/18/25, around noon time. AA stated as Resident 6 backed his wheelchair up and started to leave the lobby she saw Resident 1 wheel himself towards Resident 6. AA stated Resident 1 was by himself when he wheeled himself into the lobby. AA stated she heard Resident 6 saying “I am not done talking to her,” and she saw Resident 1 got agitated and pointed his finger towards Resident 6. AA stated Resident 1 yelled and said something to Resident 6 which she could not understand. AA stated Resident 1 wheeled his wheelchair close to Resident 6 and both residents had a fist fight. AA stated she saw Resident 6 fall from his wheelchair during the altercation. AA stated Resident 1 was on one-on-one care on the day of the altercation and she did not see any staff around Resident 1 in the lobby at the time of the incident. During an interview on 9/25/25 at 11:51 AM, CNA 3 stated she was assigned to provide one-on-one care to Resident 1 at the time of the incident. CNA 3 stated Resident 1 was placed on one-to-one care because Resident 1 was aggressive towards other residents. CNA 3 stated she pushed Resident 1 in his wheelchair to the lobby. CNA 3 stated as soon as she took her hands off from Resident 1’s wheelchair, Resident 1 quickly wheeled his wheelchair close to Resident 6. CNA 3 stated Resident 1 said “you black people,” to Resident 6 and Resident 6 said derogatory words to Resident 1. CNA 3 stated Resident 6 grabbed Resident 1’s shirt, Resident 1 pushed Resident 6's wheelchair, and then Resident 6 fell from his wheelchair. CNA 3 stated Resident 1 was the first one to say things to Resident 6. CNA 3 stated Resident 1 had told her in the past that he did not like black people because they were so loud. CNA 3 stated when she was providing one-to-one care to Resident 1, she should have kept her eyes on Resident 1 at all times. CNA 3 stated to prevent the altercation from happening she should have stood in the middle of both residents instead of standing behind Resident 1. CNA 3 stated if Resident 1 and Resident 6 did not get close to each other the incident would not have happened. During an interview on 9/25/25 at 12:31 PM, Resident 6 stated at the time of the incident he was sitting in his wheelchair in the lobby. Resident 6 stated Resident 1 showed him the middle finger then yelled and punched him. Resident 6 stated Resident 1 had shown his middle finger in the past and Resident 6 did not like that. Resident 6 stated Resident 1 pushed him and he fell from his wheelchair. Resident 6 stated he did not want any trouble. During an interview on 9/24/25 at 1:19 PM, LN 2 stated Resident 1 was on one-to-one care because Resident 1 had repeated negative interactions with other residents. LN 2 stated an altercation could happen when a resident cussed at another resident. LN 2 stated altercations could affect a resident’s safety and living situation where a resident might have to change rooms. LN 2 stated if two residents who had an altercation before shared the same space there was a chance of another altercation happening. During an interview on 9/25/25 at 4:51 PM the Administrator (ADMN) stated Resident 1 had been into altercations with other residents of the facility in the past and the facility staff had tried their best to prevent further altercations from happening. The ADMN confirmed Resident 1 was on one-on-one care at the time of the incident. The ADMN stated the altercation should not have happened. Review of the facility’s policy and procedure titled “Abuse Prohibition”, revised on 10/25/24, indicated,” …Policy; …Prevention of occurrences…Purpose: To ensure that Center staff are doing all that is within their control to prevent occurrences of abuse…for all patients…Process: 6…b. If the suspected abuse is resident-to-resident, the resident who has in any way threatened or attacked another will be removed from the setting…i. The Center will provide adequate supervision when the risk of resident-to-resident altercation is suspected…ii. The Center is responsible for identifying residents who have a history of disruptive or intrusive interactions or who exhibit other behaviors that make them more likely to be involved in altercation…” Therefore, the facility failed to provide adequate one to one monitoring (one staff member monitors one resident) to detect, prevent and de-escalate the Resident to Resident altercation incident when Resident 1 with a history of multiple resident-to-resident altercations, on one to one monitoring, made racial slurs and pushed Resident 6 on 9/18/25. This failure resulted in Resident 6 falling from his wheelchair. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.