Health inspection·August 27, 2025

The following reflects the findings of the California Department of Public Health during an investigation of complaint number 2543924 and facility reported incident numbers 2543925 and 2543923. The inspection was limited to the specific facility reported incidents and complaint investigated and does not represent the findings of a full inspection of the facility. A deficiency was written for Complaint # 2543924 and Facility Reported incident # 2543925/2543923 at F Tag 607. Health & Safety Code 1418.91(a)(b) (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. An unannounced visit was conducted at the facility on 6/18/25 to investigate an allegation of financial abuse towards Resident 1. Resident 1 is a 41-year-old female who was admitted at the facility on 5/2/25 with diagnoses of difficulty walking and need for assistance with personal care. Based on interview and record review, the facility failed to implement their policy and procedure titled, "Abuse Investigation and Reporting" for one of three sampled residents (Resident 1) when the financial abuse allegation was not reported to the California Department of Public Health (CDPH). This failure had the potential for ongoing financial abuse towards Resident 1. Findings: During a review of Resident 1's Insurance Letter Addressed to Facility (ILAF), dated 6/2/25, the ILAF indicated, "Dear Management . . . on 5/27/25, we [insurance company] received a complaint from the above-named member [Resident 1]. We require your assistance in the form of a written response for your interpretation of the encounter stated by the member below . . . Member said she gave [SSA/Social Services Assistant] her cash aid and food stamp card to bring her back food and kept the card. [Resident 1] said cash was also missing from her wallet and she [Resident 1] knows it was the [SSA] because she knew [Resident 1] was not able to get up to go into her purse." During an interview on 6/18/25 at 1:10 p.m. with Administrator in Training (AIT), AIT stated on 6/12/25, a police officer came to the facility regarding an allegation of financial abuse by the SSA towards Resident 1. AIT stated the allegation was that SSA accessed Resident 1's bank account and took out money, was not sure of amount. AIT stated the report of allegation of financial abuse was not sent to the CDPH. During an interview on 6/18/25 at 1:29 p.m. with Administrator, Administrator stated a police officer came to the facility on 6/12/25 regarding an allegation of financial abuse towards Resident 1. Administrator stated the facility did not report the allegation of financial abuse to the CDPH. During an interview on 6/26/25 at 3:59 p.m. with SSA, SSA stated she was made aware of the allegation of financial abuse by Resident 1 prior to the police officer coming to the facility around 6/5/25 when Social Services Director (SSD) told her about the allegation. SSA stated she was not sure how SSD knew about the allegation of financial abuse before 6/12/25. During an interview on 6/27/25 at 11:11 p.m. with SSD, SSD stated she was first made aware of an allegation of financial abuse on 6/2/25. SSD stated Resident 1's insurance company had sent a fax on 6/2/25 regarding multiple concerns presented to them by Resident 1 including an allegation SSA stole money from her wallet. SSD stated she responded to Resident 1's insurance company's concerns regarding the financial allegation of abuse on 6/5/25 after presenting her responses to AIT and Director of Nursing (DON). SSD stated she did not report the allegation of financial abuse to the CDPH. During an interview on 6/27/25 at 12:07 p.m. with AIT and DON, AIT stated he was aware of the letter Resident 1's insurance company had sent regarding an allegation of financial abuse. DON stated she was aware of a letter from Resident 1's insurance company regarding an allegation of financial abuse on 6/5/25 when the response was sent by SSD back to the insurance company. AIT stated the facility policy and procedure on abuse was not implemented. During a review of the facility's policy and procedure (P&P) titled, "Abuse, Neglect and Exploitation," undated, the P&P indicated, "Reporting of all alleged violations to the Administrator, state agency, adult protective services, and to all other required agencies within specified time frames. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily harm. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received." During a review of the facility's policy and procedure (P&P) titled, "Abuse Investigation and Reporting," dated 7/2017, the P&P indicated, "All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ("abuse") shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies . . . The State licensing/certification agency responsible for surveying/licensing the facility." In violation of the above cited, the facility failed to report alleged financial abuse to the CDPH within 24 hours. This failure resulted in the CDPH being unaware of the alleged abuse and had the potential to result in abuse to continue. This violation had a direct or immediate relationship to the health, safety, or security of Resident 1 and represents a Class B citation.