Health inspection·March 24, 2026

The following reflects the findings of the California Department of Public Health during the investigation of a facility reported incident number 2700705 conducted during an abbreviated survey. Facility Reported Incident: 2700705 A deficiency was written for facility reported incident 2700705 at F-tag 609. 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 1/6/26, an announced visit was conducted at the facility to investigate a facility reported incident regarding alleged abuse towards Resident 1. Resident 1 was a 66-year-old female, admitted to the facility on 1/28/24 with diagnoses of schizoaffective disorder bipolar type (a chronic mental health condition combining schizophrenia symptoms hallucinations, delusions, disorganized thinking with manic episodes and sometimes depression), bipolar disorder (a chronic mental illness characterized by extreme shifts in mood, energy, and activity levels, alternating between high-energy, low-mood, and depressive episodes.), anxiety disorder (persistent, excessive fear or worry that interferes with daily life, going beyond occasional stress to cause significant distress.), and schizophrenia (a severe, chronic mental disorder causing abnormal reality interpretation through hallucinations, delusions, and disorganized thinking) Based on interview and record review, the facility failed to ensure allegations of abuse were reported to the Department within 24 hours for one sampled resident (Resident 1). This failure resulted in the Department being unaware of alleged abuse and had the potential for investigation of the alleged abuse to be delayed. Findings: During a review of Resident 1's "SBAR (situation, background, appearance, and review) Communication Form," (SBAR) dated 12/21/25, the SBAR indicated, "Attention brought by CNA [Certified Nursing Assistant] that resident sustained a skin tear while changing her and doing ADLs [Activities of Daily Living - basic self-care tasks like bathing, dressing, toileting, and eating], resident hand accidentally was bumped on side rail." During a review of Resident 1's "Special Problems," (SP) dated 12/21/25, the SP indicated, "[Resident 1] screamed 'Ouch you [expletive] you hit me' told her I didn't hit you, you hit yourself with the siderail." The SP was signed by CNA 3. During a review of Resident 1's "Nurse's Notes," (NN) dated 12/23/25, the NN indicated, "SOC 341 [form used by mandated reporters to document and report suspected abuse or neglect of elders] was filled due to resident [1] claiming that she was hit on the right hand and sustained a skin tear during ADLs." During a review of the facility's SOC 341 form that was faxed to the Department, the fax date was 12/23/25 at 5:12 p.m. (two days after the alleged incident). During a concurrent observation and interview, on 1/6/26 at 1:55 p.m. with Resident 1, Resident 1 stated on 12/21/25, two CNAs were providing care. Resident 1 stated one of the CNAs was gripping and told her she screamed too much, and she should say please and thank you. Resident 1 stated her hand was injured during care and she told the CNAs you hit me. Resident 1's right hand was noted with a scab the size of a dime over the pinky finger knuckle. During an interview on 1/6/26 at 3:30 p.m. with CNA 2, CNA 2 confirmed she cared for Resident 1 on 12/21/25. CNA 2 stated she requested CNA 3 to assist with care for Resident 1. CNA 2 stated during care Resident 1 was injured and stated Resident 1 hit herself on the bedrail causing a skin tear. CNA 2 stated, "[Resident 1] told us [CNA 2 and CNA 3] ouch you hit me, and we [CNA 2 and CNA 3] just said we did not hit you." During an interview on 1/6/26 at 3:49 p.m. with the Director of Nursing (DON), DON stated Resident 1 made allegations to CNA 2 and CNA 3 that CNA 2 and CNA 3 hit Resident 1. DON stated CNA 2 and CNA 3 did not report Resident 1's allegations. During a review of the facility's policy and procedure (P&P) titled, "Abuse Prevention Program," revised 7/22/21, the P&P indicated, "4. When an alleged or suspected case of mistreatment, neglect, injuries of an unknown source, or physical abuse is reported, the Nursing Supervisor or Supervisor of the mandated reporter, shall notify the appropriate person and agencies as listed below: a. The Resident's Responsible Party; b. The Resident's attending physician; c. The Ombudsman or Local Law Enforcement; and d. CDPH . . . 5. Notices to the above agencies/individuals must be submitted by telephone or confirmed fax within 24 hours from the time the incident occurred utilizing the SOC 341 form. . . 13. A person shall not knowingly; . . . Fail to report an incident of mistreatment or other offense; . . . The facility will protect residents from harm during investigations of abuse allegations. . . 1. During abuse investigations, residents will be protected from harm by the following measures: a. Staff will ensure the immediate physical safety of the resident first by ensuring that the accused perpetrator is not near the resident. Staff will observe to ensure that both parties remain separated until further investigation. . . All alleged/suspected violations and all substantiated incidents of abuse will be promptly reported to the Ombudsman or law enforcement and CDPH as required by law and in accordance with this policy. . . If a Resident sustained no serious bodily injury: Within 24 hours: Report the incident by phone to law enforcement. Within 24 hours: Submit a completed SOC 341 to the Ombudsman, law enforcement, and CDPH." In violation of the above cited, the facility failed to ensure staff reported timely an allegation of abuse to the Department. This violation had a direct or immediate relationship to the health, safety, or security of Resident 1 and constitutes a class "B" citation.