Health inspection·January 15, 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 9/22/25 at 12:45 p.m., the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate two Facility Reported Incidents and one complaint regarding resident abuse. The Department determined the facility failed to report an allegation of abuse directly to the facility administrator and to the Department (a state agency that licenses, regulates, and inspects skilled nursing facilities (SNFs) to ensure they comply with state and federal regulations) within two hours after the suspicion of abuse was recognized on 9/18/25 by facility staff for Resident 1. This failure delayed the facility and the Department's abuse investigation, potentially allowing continued abuse of Resident 1 and other residents, or causing further psychosocial harm. A review of Resident 1's "ADMISSION RECORD", indicated Resident 1 was admitted to the facility with diagnoses which included Alzheimer's Disease (a progressive brain disorder that causes memory loss, confusion, and other cognitive decline) Unspecified Dementia (a group of conditions that cause a gradual decline in cognitive abilities, such as memory, thinking, language, and judgment, severe enough to interfere with daily life), Moderate with Other Behavioral Disturbance, and Unspecified Mood Disorder (a clinical diagnosis for someone exhibiting symptoms of a mood disorder that do not meet the full criteria for other diagnoses). During a telephone interview on 9/22/25 at 10:25 a.m. with Certified Nurse Assistant (CNA) 2, CNA 2 stated, during the night shift (NOC) she witnessed a suspected case of staff to resident (Resident 1) abuse on 9/18/25 at approximately 4:30 a.m. when CNA 1 sat in the doorway of Resident 1's room preventing Resident 1 from exiting. CNA 2 stated that she was going to report the incident to the Administrator (ADMIN) on the morning of 9/18/25 after her shift ended but did not. During an interview on 9/22/25 at 1:05 p.m. with the administrator (ADMIN), the ADMIN confirmed the alleged abuse occurred on 9/18/25 at approximately 5 AM and the nursing assistant (NA) also working the NOC shift on 9/18/25, made the initial report to her at approximately 9:30 a.m. that morning. The ADMIN confirmed that staff knew they were mandated reporters (individuals who are legally required to report suspected abuse or neglect to the proper authorities) and knew the "3, 2, 1" acronym: 3 entities (Police, the Department, ADMIN), 2 hours, 1 reporter. During an interview on 9/22/25 at 4:40 p.m. with the Assistant Director of Nursing (ADON), the ADON stated, staff knew the process for abuse reporting included steps on what to do, in the absence of the ADMIN. The ADON stated seclusion (the involuntary confinement of a person alone in a room or an area where the person is physically prevented from leaving) of Resident 1 in her room should have been reported to the proper authorities within 2 hours of the occurrence. The ADON confirmed that the notification to the Police Department did not occur until 10:00 a.m. on 9/18/25 and was not within the required 2-hour timeframe. The ADON further confirmed, the report to the Department was not made until 10:36 a.m. and did not meet the facility's 2-hour reporting requirements for abuse. During an interview on 9/22/25 at 5:10 p.m. the ADMIN confirmed, the facility's timeline for reporting suspected abuse was not followed when a written report was not faxed within 2 hours to the Department and Police Department contact was not made immediately. Review of an undated facility document titled, "Process for Abuse Reporting," indicated, "...WITHIN THE FIRST 2 HOURS FAX SOC-341 [a California state form, officially titled "Report of Suspected Dependent Adult/Elder Abuse" that is used to report suspected instances of abuse to the proper authorities and to document and report known or suspected abuse or neglect of an elderly person ] TO CDPH [California Department of Public Health - the Department] AND OMBUDSMAN [an independent, neutral official who investigates complaints and mediates disputes between individuals and an organization, such as a skilled nursing facility]...CALL NON-EMERGENCY POLICE DEPT [department] AND OBTAIN REPORT NUMBER...CALL ED [Executive Director - ADMIN]/DON/ADON IMMEDIATELY...CALL MD [medical doctor]/RP [responsible party] IMMEDIATLEY..." Review of an undated facility training module titled, "Preventing Abuse (Hand in Hand by CMS [Centers for Medicare & Medicaid Services-a federal agency that provides health coverage to millions of people through programs like Medicare, Medicaid] Module 2)," indicated, "..Reporting Procedures...All nursing home staff are legally mandated reporters and must report abuse or suspected abuse immediately to the administrator after ensuring the elder's safety...Immediate Reporting: Report at the time you notice something...Chain of command: While you can inform supervisors, your legal responsibility is to ensure the administrator is notified directly..." The Department determined the facility failed to report an allegation of abuse directly to the facility administrator and to the Department within two hours after the suspicion of abuse was recognized on 9/18/25 by facility staff for Resident 1. This failure delayed the facility and the Department's abuse investigation, potentially allowing continued abuse of Resident 1 and other residents, or causing further psychosocial harm. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents and is a B citation.