Health inspection·August 13, 2025

The following reflects the findings of the California department of Public Health during the investigation of facility reported incident number 965763. The inspection was limited to the specific facility reported incident investigated and does not represent the findings of a full inspection of the facility. A deficiency was written for facility reported incident 965763 at F-tag 607/D. Health & 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 6/4/25, an unannounced visit to the facility was conducted to investigate an allegation of financial abuse towards a resident. Resident 3 is an 82-year-old female who was admitted at the facility on 6/11/25 with diagnoses of difficulty walking, need assistance with personal care, and muscle weakness. Based on interview and record review, the facility failed to follow their policy and procedure (P&P) on abuse, neglect, exploitation or misappropriation reporting and investigating when the facility did not report an allegation of financial abuse to California Department of Public Health (CDPH) within 24 hours of an allegation for one of seven sampled residents (Resident 3). This failure resulted in the Department being unaware of the alleged financial abuse and had the potential to result in ongoing abuse. Findings: During a review of the "SOC-341 (Report of Suspected Dependent Adult/Elder Abuse)," dated 6/2/25, the SOC-341 indicated, "REPORTED TYPES OF ABUSE. . . Financial. . . On 5/15 (Family Member [FM] 1) contacted Social Services via phone call. She stated she was worried about paperwork that was signed by (Resident 3). (FM 2) had brought in paperwork and had (Resident 3) sign without notifying any family. . . On the same day Social Services went to talk to (Resident 3). (Resident 3) was asked what paperwork she signed, and she stated (FM 2) had her sign financial paperwork so he is able to help pay her bills. (Resident 3) did not know much about the paperwork. (Resident 3) stated if she needs to she will get authorities involved. On 6/2/25 Social Services talked to (FM 2) via phone call. (FM 2) stated (Resident 3) did sign POA (Power of Attorney - legal document that grants one person the authority to act on behalf of another person) paperwork. (FM 1) does not want (FM 2) to have any authority over (Resident 3) . . . Other neighbors have told (FM 1) they do not trust (FM 2), and he may have ill intention." During a review of Resident 3's "Admission Record (AR)," dated 6/4/25, the AR indicated FM 1 was Resident 3's Responsible Party (RP). During a review of Resident 3's Brief Interview for Mental Status (BIMS) dated 3/5/25, the BIMS indicated Resident 3 had a score of 13 (range of scores is 0-15 with a score of 13-15 indicating the resident is cognitively intact). During an interview on 6/4/25 at 1:11 p.m. with Resident 3, Resident 3 stated FM 1 was her granddaughter and FM 2 was her neighbor. Resident 3 stated she "may have given" FM 2 the POA after she signed a paperwork he brought. Resident 3 stated she was not sure what the paperwork was about. Resident 3 stated "the inheritance" should go to FM 1 and that the POA for FM 2 needed to be revoked. During a concurrent interview and record review on 6/4/25 at 2:55 p.m. with the Administrator, Resident 3's "Communication Note (CN)," dated 5/15/25 was reviewed. The CN indicated FM 1 told the facility she did not agree with FM 2 managing Resident 3's finances and requested to be informed if Resident 3 was asked to sign any further documents. The administrator stated since FM 1 raised the concern about Resident 3's finances, she maybe is also trying to get Resident 3's assets (valuable possessions). The administrator stated the facility should have notified the California Department of Public Health (CDPH) about the allegation of financial abuse by 5/16/25. During a review of the facility's P&P titled, "Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating," dated September 2022, the P&P indicated, "If resident abuse, neglect, exploitation, misappropriation of 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. . . 'immediately' is defined as. . . within 24 hours of an allegation that does not involve abuse or result in serious bodily injury." In violation of the above cited, the facility failed to report alleged financial abuse to the Department within 24 hours for Resident 3. This failure resulted in the Department being unaware of the alleged financial 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 patients and represents a Class B citation.