Health inspection·October 29, 2025

The following reflects the findings of the California Department of Public Health during an investigation of complaint number 2563984. The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. A deficiency was written for complaint number 2563984 at F609. 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 8/5/25 to investigate an allegation of physical abuse towards Resident 1. Resident 1 was a 66-year-old male who was admitted to the facility on 10/27/21 with diagnoses of anxiety disorder (a mental health condition characterized by excessive and persistent worry, fear, and nervousness that can significantly interfere with daily life), muscle weakness, legal blindness (severe vision loss with a visual acuity of 20/200 which as a person can see details at 20 feet [ft] that a person with normal vision can see at 200 ft) , history of falling, and need for assistance with personal care. Based on interview and record review, the facility failed to report an allegation of physical abuse of one of three sampled residents (Resident 1) to the California Department of Public Health (CDPH). This failure had the potential for abuse to continue and had the potential for other residents to be abused. Findings: During a review of Resident 1's "ED (Emergency Department) Physician Notes (EDPN)," dated 7/14/25, the EDPN indicated Resident 1 arrived at the acute hospital emergency department stating, "Needed to get out of truck and that they [unknown] were crossing the road, and the [facility] staff is abusing [Resident 1]." During an interview on 8/5/25 at 2:05 p.m. with Administrator, Administrator stated he was the abuse coordinator (a designated staff member responsible for preventing and addressing abuse within the facility). Administrator stated on 7/14/25 he was called into Resident 1's room by staff (not specified who the staff was) due to Resident 1's behavior of purposely kneeling on the floor, refusing food and medication, and requesting to be sent to the acute hospital. Administrator stated Resident 1 told him, "You guys [not specific which staff] are hitting and kicking me." Administrator stated a report for Resident 1's allegation of abuse was not submitted to the CDPH as of 8/5/25 despite the allegation of staff abusing Resident 1 being made on 7/14/25. Administrator stated there should have been a report of allegation of abuse submitted to the CDPH. During a review of the facility's policy and procedure (P&P) titled, "Reporting Abuse to State Agencies, and Other Entities," undated, the P&P indicated, "All alleged/suspected violations and all substantiated incidents of abuse will be promptly reported to the Ombudsman or law enforcement and CDPH (California Department of Public Health) as required by law and in accordance with this policy. . . If a Resident sustained no serious bodily injury . . . Within 24 hours." In violation of the above cited, the facility failed to report alleged financial abuse to the CDPH. 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.