Health inspection·March 18, 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 1/23/26, at 9:33 am, the Department conducted an unannounced visit to the facility to investigate one complaint and one facility reported incident regarding resident abuse and infection control. The facility failed to identify and report to the Department, an allegation of financial abuse for Resident 1 when Resident 1 reported that his money was missing from his wallet after seeing a staff member holding his wallet. This failure resulted in a delay of the Department's investigation into Resident 1's allegation of theft and had the potential to affect other residents of the facility. A review of Resident 1's "ADMISSION RECORD," indicated that he was admitted in the Summer of 2022. A review of Resident 1's "MDS [Minimum Data Set, a comprehensive assessment of a resident's functional, medical, psychosocial, and cognitive status]," dated 10/31/25, indicated Resident 1 had a Brief Interview for Mental Status Score of 15 (BIMS, a standardized 0-15 point cognitive assessment used primarily upon admission to long-term care facilities to gauge mental acuity, with higher scores indicating better cognition), which indicated Resident 1's cognition (the mental process of knowing and understanding) was intact. A review of Resident 1's "Progress Notes," dated 1/20/26, indicated, "...On 01/19/26 @ [at] 0500H [5 AM], resident [Resident 1] reported missing approximately $120-$140 [dollars] from his wallet. Resident stated he witnessed laundry staff [LS 1] holding his wallet while resident was asleep. Resident reassessed at time of report and noted to be cognitively intact (BIMS 15), calm, and able to verbalize concern clearly. Writer and SSD [Social Service Director] met with resident to discuss resident concern, resident rights, reporting options ([Department]/State/PD [police department]/Ombudsman [long term care resident advocate]), facility grievance [formal complaint] process, and investigation steps. Resident stated he does NOT want to file a formal grievance/complaint and "just wants staff to know". Resident was offered option to report concern externally and resident declined at this time. Laundry staff [LS 1] interviewed regarding allegation and vehemently [strongly] denied holding resident's wallet or taking any money. Investigation completed with no additional evidence identified to confirm theft at this time. Resident educated on valuables safety options (secure storage/avoid keeping cash). Facility offered secured valuables storage and lockbox to be provided once available. Resident informed of facility process for lost personal property and agreed to reimbursement per facility policy; resident advised reimbursement does not affect his rights to file a grievance or report to [Department]/State/Ombudsman at any time. Resident updated on findings, verbalized understanding, and case closed at this time..." A review of a facility provided document titled, "Theft/Loss Report," dated, 1/19/26, indicated that Resident 1 had a $120-$140 dollars in twenty dollar bills missing. Further review of the document, under the section titled, "Facility Action Taken to Find Missing Item," indicated, "...Cash was not located, DON [Director of Nursing] and SSD met with resident regarding concern, resident rights and reporting options. Resident declined to file a formal grievance and just wanting money replaced..." During an interview on 1/23/26, at 12:28 PM, with the SSD, the SSD stated that Resident 1 reported to her and to the DON that he lost his money (on 1/19/26). The SSD further stated that Resident 1 filled out a theft and lost form regarding his lost money. The SSD stated that Resident 1 had reported that he saw LS 1 holding his wallet in his room. The SSD stated that Resident 1 was offered to report the incident to the Department, police and Ombudsman. The SSD further stated that Resident 1 declined to report the incident and just wanted his money to be reimbursed. The SSD stated that she and the DON interviewed LS 1 and LS 1 denied holding Resident 1's wallet. The SSD further stated that LS 1 told them that he went to Resident 1's room to place the clothes in the closet while Resident 1 was sleeping. The SSD stated that Resident 1 told them that he did not witness LS 1 taking the money and did not confront LS 1. The SSD confirmed that Resident 1's money was not found. During an interview on 1/23/26, at 1:39 PM, with Resident 1, Resident 1 stated he woke up because he felt someone was in his room. Resident 1 further stated that when he looked up, he saw LS 1 putting clothes in the closet at 5 in the morning. Resident 1 stated he just saw LS 1 holding the wallet but did not see if LS 1 took out any cash. Resident 1 further stated he did not say anything but as soon as LS 1 left the room, he checked his wallet and noticed his $140 was missing from his wallet. Resident 1 stated that the money was still there before he slept the night before. Resident 1 further stated that seven $20 bills were gone. Resident 1 stated that when the CNA came in his room, he reported it to the CNA and to the head nurse. Resident 1 further stated he signed some paperwork for the lost money. Resident 1 stated that he reported it to the SSD and the DON. Resident 1 confirmed that the facility offered to report the incident to the Department, the police and the Ombudsman, but he declined because he did not want the trouble of reporting and he just wanted his money back. During an interview on 1/23/26, at 3:15 PM, with the DON, the DON stated that when a resident reported a missing item or cash, the SSD would initiate an investigation. The DON further stated that after a thorough investigation, they would involve the Administrator (ADM) and see if it would be a case of abuse and if it would be reportable. The DON stated that they would involve Human Resources (HR) if a staff member had stolen something. The DON further stated that if it was an abuse case, they would trigger the abuse protocol which was to contact the Department, Ombudsman, and Police Department. The DON stated that the potential outcome for a resident if a resident's items were stolen or missing would be degrading the resident's rights because this was the resident's home. The DON further stated that the facility investigated Resident 1's allegation on the same day that he reported it. The DON stated the investigation was a laundry staff member (LS 1) allegedly was holding the wallet of Resident 1 but Resident 1 did not see LS 1 removing the money from his wallet. The DON further stated that Resident 1 claimed he counted his money in the wallet the night before and noticed $120-$140 was missing when he woke up. The DON stated if the amount of money or the value of the item missing was above $100, they would report it to the police and the Department, but if the resident wanted it to be reported then the amount did not matter. The DON stated reporting was always offered to the residents and the residents were educated about reporting to the Department. The DON confirmed Resident 1's allegation was not reported to the Department because Resident 1 declined to report the incident when he was given the option to report. During a concurrent interview and record review on 1/23/26, at 4:36 PM, with the ADM, Resident 1's progress notes was reviewed. The ADM confirmed that the facility did not report the incident to the Department. The ADM stated that he was not aware that the incident was an alleged incident of abuse and usually the facility would act on behalf of the resident. The ADM stated that Resident 1 was given a choice to report the incident to the police and not the Department. The ADM further stated that he was under the impression that this was not an abuse because he was not aware that Resident 1 accused a staff member of stealing his money. The ADM stated that in the progress notes it was not stated that Resident 1 was accusing the staff of stealing his money. The ADM further stated that his understanding was that Resident 1 had some money missing from his wallet. The ADM stated that both the facility and the residents had reserved the right to have a choice in reporting. The ADM further stated that there was no alleged abuse going on and no misappropriation of funds that happened. The ADM stated it was 100% not a potential for financial abuse because Resident 1 did not see LS 1 take the money and Resident 1 did not want to file a grievance. The ADM further stated that when they reported something there was an alleged abuse, but in this case, there was no malicious intent. The ADM stated that Resident 1 reported that some of his money was missing, and that LS 1 was present. The ADM further stated that their abuse policy did not apply to this scenario because there was not enough evidence to deem that it was a misappropriation of the resident's funds. During an interview on 1/23/26, at 4:59 PM, with Resident 1, Resident 1 stated he did not ask a staff member to report the incident to the Department and police department, but he did report it to the CNA, the nurse, the SSD and the DON. Resident 1 stated when the incident happened, he felt ripped off, stolen, and upset. Resident 1 further stated that the incident made him think that this could potentially happen again. Resident 1 stated that he saw LS 1 putting the wallet back on the table, but LS 1 did not notice that he was awake. Resident 1 further stated when LS 1 left, he immediately checked his wallet, and the money was gone, and he said to himself that he (LS 1) stole his money. Resident 1 stated that LS 1 should not have held his wallet in the first place. During an interview on 1/23/26, at 5:05 PM, with the ADM and the DON, both the ADM and the DON stated that there was nothing to be reported because there was no theft incident, Resident 1 just lost his money, and it was not proven that the LS took his money. The ADM and the DON stated that LS 1 did not have any records, and he had been working at the facility for 19 years. During a phone interview on 1/29/26, at 2:02 PM, with the DON, the DON confirmed that Resident 1's cash was not included in the inventory sheet. The DON stated that the incident was not reported to the police department and Ombudsman. During a review of Resident 1's "INVENTORY OF PERSONAL EFFECTS, " dated 7/4/22, the document did not include any cash. A review of the facility's policy and procedure titled, "Resident's Personal Property," dated 8/25/21, indicated, "...Any loss or breakage of a Resident's personal item will be properly documented on the Theft/Loss form and/or Grievance form by the person receiving the report, and then referred to the Administrator..." A review of the facility's policy and procedure titled, "Investigating Incidents of Theft and Loss," revised April 2017, indicated, "...All reports of theft or misappropriation of resident property shall be promptly and thoroughly investigated...Residents have the right to be free from theft and Loss...Should an alleged or suspected case of staff misappropriation of resident property be reported, the facility Administrator, or his/her designee, will notify the following persons or agencies within twenty-four (24) hours of such incident, as appropriate: a. State Licensing and Certification Agency; b. Ombudsman; c. Resident Representative; d. Adult Protective Services; e. Law Enforcement Officials...The administrator will report the results of the investigation to the local police department, the ombudsman, and to the state survey and certification agency within five (5) working days of the incident..." A review of the facility's policy and procedure titled, "Resident Rights," revised October 2025, indicated, "...Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to...be free from abuse, neglect, misappropriation of property, and exploitation..." A review of the facility's policy and procedure titled, "Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating," revised September 2022, indicated, "...Reporting Allegations to the Administrator and Authorities 1. If resident abuse, neglect, exploitation, misappropriation or resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. 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 (where state law provides jurisdiction in long-term care); e. Law enforcement officials..." Therefore, the facility failed to identify and report to the Department an allegation of financial abuse for Resident 1 when Resident 1 reported that his money was missing from his wallet after seeing a staff member holding his wallet. This failure resulted in a delay of the Department's investigation into Resident 1's allegation of theft and had the potential to affect other residents of the facility. This violation had a direct or immediate relationship to the health and safety, or security of Resident 1.