Health inspection·April 1, 2026

California Health & Safety Code, Section 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) Failure to comply with the requirements of this section shall be a Class B Citation. California Code, Welfare and Institutions Code, Section 15630 (b)(1) A mandated reporter who, in their professional capacity, or within the scope of their employment, has observed or has knowledge of an incident that reasonably appears to be physical abuse, as defined in Section 15610.63, abandonment, abduction, isolation, financial abuse, or neglect, or is told by an elder or dependent adult that they have experienced behavior, including an act or omission, constituting physical abuse, as defined in Section 15610.63, abandonment, abduction, isolation, financial abuse, or neglect, or reasonably suspects that abuse, shall report the known or suspected instance of abuse by telephone or through a confidential internet reporting tool, as authorized by Section 15658, immediately or as soon as practicably possible. If reported by telephone, a written report shall be sent, or an internet report shall be made through the confidential internet reporting tool established in Section 15658, within two working days. Code of Federal Regulations, Title 42, Section 483.12 (c)(1) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (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. Code of Federal Regulations, Title 42, Section 483.25 (d)Accidents. The facility must ensure that - (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. 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, but not be limited to, 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 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 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 2/17/26 at 8:35 a.m., the California Department of Public Health (the Department) conducted an unannounced visit to the facility to do a recertification survey. During a review of Resident 138's (Patient 138) medical record, the department determined that Patient 138 eloped (the act of leaving a facility unsupervised and without prior authorization) from the facility on 11/19/2025. The facility did not report the incident regarding Resident 138's elopement to the department. As a result of the investigation, the department determined the facility failed to ensure patient safety when the facility did not report an incident regarding Patient 138's elopement from the facility on 11/19/25. This failure placed Patient 138 at risk for serious injury, harm, or death and reducing the facility's potential in ensuring Patient 138's immediate safety, prevention from fatal harm, potential neglect or abuse. Review of Patient 138's "Admission Record," indicated Patient 138 was admitted on November 19, 2025, with diagnoses including Acute Pyelonephritis (a serious bacterial infection of the kidney, usually caused by a bladder infection that has spread upwards). Review of Patient 138's medical record indicated, a history of diabetes type 1 (DM 1- a chronic autoimmune condition where the body's immune system mistakenly attacks and destroys insulin-producing cells in the pancreas), bacteremia (the presence of bacteria in the blood stream),bipolar disorder (a chronic mental health condition characterized by intense, extreme shifts in mood, energy, and activity levels), and Post-Traumatic Stress Disorder (PTSD, a mental health condition triggered by experiencing or witnessing terrifying events, causing long-lasting symptoms like nightmares, flashbacks, severe anxiety, and avoidance of reminders ). Patient 138's medical record also indicated, an outside interfacility medical record review dated 11/19/25, which indicated Patient 138 has history of marijuana use and intravenous methamphetamine (controlled drug that needs prescription, highly addictive) abuse. Review of Patient 138's order dated 11/19/25 indicated she was receiving intravenous (IV) antibiotic, "Ertapenem Sodium Injection Solution 1 Gram (IV antibiotic) use 50 ml [milliliter, unit of measure] intravenous one time a day...End Date...11/24/25." Review of Patient 138's "Progress Note (PN)," dated 11/19/25 at 22:58 (10:58 p.m.), indicated, "Roughly around 7:00 PM, CNA [Certified Nurse Assistant] notified the charge nurse that the resident [patient] [138] was not in her room. Nurses and CNAs conducted a facility-wide search and were unable to locate the resident. CNA reported last seeing the resident approximately 30 minutes prior to the elopement. 911 [police or emergency services] was called and the situation was reported. DON [Director of Nursing] and Administrator [ADM] were also notified. Resident alert and oriented x4 [conscious and aware to self, place, time, and surroundings] and is a self-responsible party (self-RP) [can decide for own self]." During a review of facility's clinical record for Patient 138, no evidence of the following: An individualized nursing assessment for Patient 138 addressing risks for unauthorized departure. Documentation of Patient 138's behavioral and medical history evaluation in relation to supervision needs. Documentation of physician notification at the time of departure. Documentation verifying Patient 138 safety during the period of absence. Documentation of Interdisciplinary Team Notes related to Patient 138's elopement. Documentation of a police report or case number. Documentation of Patient 138's stated intent to leave against medical advice (AMA) nor a refusal to sign an AMA form. Patient 138 remained absent overnight without documented verification of her location or her safety. During an interview on 2/20/26 at 11:30 a.m., the Administrator and Director of Nursing (DON) confirmed that the facility was unaware of Patient 138's whereabouts since she eloped on the night of 11/19/2025. The DON and ADM also confirmed that the facility did not report the elopement incident to the Department. The ADM and DON stated, Patient 138 came back the following day to discuss her care. No documented evidence that Patient 138 came back the following day nor what the patient's condition was on return. No documented evidence that Patient 138 was found at all. During a review of the facility's policy and procedure titled, "Elopement Prevention and Response Policy," undated, indicated," ...facility identifies residents at risk for elopement and follows a structured response when a resident leaves the facility without authorization, or required supervision. Actions are based on assessed risk, resident capacity, and regulatory requirements... Therefore, the department determined the facility failed to ensure patient safety when the facility did not report an incident regarding Patient 138's elopement from the facility on 11/19/25. This failure placed Patient 138 at risk for serious injury, harm, or death and reducing the facility's potential in ensuring Patient 138's immediate safety, prevention from harm, potential neglect or abuse. This violation had a direct or immediate relationship to the health, safety, or security of Long-Term Care patients or residents.