Health inspection·January 21, 2026

The following reflects the findings of the California Department of Public Health during the investigation of a facility reported incident. Facility Reported Incident Number: 2600590 The inspection was limited to the specific facility reported incident investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for facility reported incident number 2600590 at F600-G. F600 §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must- §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; INTENT §483.12(a)(1) Each resident has the right to be free from abuse, neglect and corporal punishment of any type by anyone. §483.40 Behavioral Health Services Based on the comprehensive assessment of a resident, the facility must ensure that- (3) A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. Cal. Code Regs. Tit. 22, § 72315 - Nursing Service-Patient Care (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. Cal. Code Regs. Tit. 22, § § 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 9/9/25, an unannounced visit was conducted at the facility to investigate a facility reported incident regarding an allegation of physical abuse from a staff towards Resident 1. Resident 1 is an 80-year-old male who was admitted to the facility on 1/11/21 and has diagnoses of Alzheimer's Disease (memory loss), Major Depressive Disorder (mood disorder), and Legal Blindness. Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from physical abuse (any intentional act causing injury or trauma to another person through bodily contact) when Certified Nursing Assistant (CNA) 1 intentionally hit Resident 1 on the right side of his face while CNA 1 and CNA 2 were changing Resident 1's adult brief. This failure resulted in Resident 1, who has dementia, crying and having redness to his face indicating immediate psychological distress and physical impact and heightened risk of ocular, dental, or other injury to the face. This failure violated the resident's right to a safe and dignified home-like environment and to appropriate treatment and services to maintain the highest practicable psychosocial wellbeing Findings: During a review of the "SOC-341 (Report of Suspected Dependent Adult/Elder Abuse)," dated 8/26/25, the SOC-341 indicated, "A CNA (2) stated another CNA (1) slapped a resident (Resident 1) in the face while providing care." During a review of Resident 1's "Summary of the Incident (SI)," documented by Administrator, dated 8/31/25, the SI indicated, "08/26/25 0540 (approximately) . . . (CNA 2) and (CNA 1) entered (Resident 1's) room and attempted to change (Resident 1). (CNA 2) was positioned on the right side of (Resident 1's) bed (closer to the room door) and (CNA 1) was positioned on the left side of (Resident 1's) bed (next to the window). (Resident 1) began hitting (CNA 2) and (CNA 1), and then (Resident 1) grabbed (CNA 1's) hands. (CNA 1) was able to pull her hands away from (Resident 1's) grip with (Resident 1) scratching (CNA 1's) right forearm. (CNA 1) looked down at her hand and hit (Resident 1) on the right side of his face with (CNA 1's) opened, left hand. . . Conclusion: Based on interviews and investigation the allegation (CNA 1 hitting Resident 1 on the right side of his face) is verified." During a review of Resident 1's "Admission Record (AR)," dated 8/31/25, the AR indicated, "DIAGNOSIS. . . ALZHEIMER'S DISEASE (loss of ability to think, remember, and reason effectively) . . . MAJOR DEPRESSIVE DISORDER (mood disorder [mental health condition that primarily affects a person's emotional state] that causes a persistent feeling of sadness and loss of interest) . . . LEGAL BLINDNESS (impaired ability to see objects clearly)." During a review of Resident 1's "Quarterly Minimum Data Set (MDS - an assessment tool)," dated 6/17/25, the MDS indicated on Section C (Brief Interview for Mental Status), Resident 1 had a score of 3 on a scale of 0-15 (scores of 0-7 indicate severely impaired cognition [difficulty remembering things, concentrating, making decisions and solving problems]). The MDS indicated on Section GG (Functional Abilities - capacity of an individual to perform tasks), Resident 1 was wheelchair bound. The MDS indicated Resident 1 required substantial or maximal assistance (staff lifts or holds trunk or limbs and provides more than half the effort) with toileting hygiene (ability to maintain perineal hygiene [cleaning of the area between the anus and the genitals], adjust clothes before and after voiding [urinating] or having a bowel movement). The MDS indicated Resident 1 required partial or moderate assistance (staff lifts, holds, or supports trunk or limbs, but provides less than half the effort) with rolling left and right on bed. The MDS indicated Resident 1 was unable to walk. During a review of Resident 1's "Documentation Survey Report (DSR - ADL [Activities of Daily Living - basic self-care tasks needed to live independently] flowsheet)," dated August 2025, the DSR indicated, on 8/25/25 night shift (10 p.m. to 6 p.m.), CNA 2 documented Resident 1 had no behavior symptoms. During a review of Resident 1's "Care Plan (CP - personalized, written document that outlines an individual's specific health conditions, needs, goals, and preferences)," initiated 5/24/24 and revised on 8/30/25, the CP indicated, "(Resident 1) is/has episodes to demonstrate physical behaviors (swinging at staff when assisting with ADL function) r/t (related to) Alzheimer's disease. . . Interventions (any treatment or action that staff perform to enhance resident outcomes) . . . Provide physical and verbal cues to alleviate anxiety (feeling of worry); give positive feedback (to appreciate certain acts or behaviors), encourage to verbalize source of agitation (feeling of irritability, mental distress or restlessness)." During a review of Resident 1's "Change in Condition Evaluation (CCE)," documented by Licensed Vocational Nurse (LVN) 1 on 8/26/25 at 7:14 a.m., dated 8/26/25, the CCE indicated, "(LVN 1) were called from the office around 6:05 am regarding an allegation of a witnessed of physical abuse with the resident (1) and a CNA (1) involved. MD (Medical Doctor) was notified; on Neuro check (evaluates brain and nervous system [network of nerve cells and fibers that transmits nerve impulses between parts of the body] functioning) per policy and monitoring for any skin changes and psychosocial (mental and emotional state) changes." The CCE indicated there were no injuries noted on Resident 1. During an interview on 9/9/25 at 4:08 p.m. with Executive Director (ED), ED stated, "(CNA 1) was interviewed three of four times, (CNA 1) did admit to the incident (CNA 1 hitting Resident 1 on the right side of his face on 8/26/25 at around 5:40 a.m.)." ED stated the physical abuse incident (CNA 1 hitting Resident 1 on the right side of his face on 8/26/25 at around 5:40 a.m.) was substantiated (verified with investigation, and CNA 1 and CNA 2 interviews) on 8/31/25. During an interview on 10/8/25 at 2:45 p.m. with CNA 1, CNA 1 stated on 8/26/25 at around 5:45 a.m., CNA 1 was helping CNA 2 (CNA assigned to Resident 1 on 8/25/25 night shift) change Resident 1's brief. CNA 1 stated Resident 1 held CNA 1's hands and tried to bite CNA 1. CNA 1 stated, "My one hand hit (Resident 1's) face (right side)." CNA 1 stated after she hit Resident 1's face, Resident 1 "was not fighting too much" then CNA 1 and CNA 2 finished changing Resident 1's brief. CNA 1 stated "maybe" hitting Resident 1 on the right side of his face was considered physical abuse. CNA 1 stated she did not report the physical abuse incident (CNA 1 hitting Resident 1 on the right side of his face on 8/26/25 at around 5:40 a.m.) to anybody. During an interview on 10/8/25 at 4:31 p.m. with CNA 2, CNA 2 stated she was the CNA assigned to Resident 1 on 8/25/25 night shift (10 p.m. to 6 a.m.). CNA 2 stated on 8/26/25 at around 5:40 a.m., CNA 2 asked CNA 1 to help her change Resident 1's brief. CNA 2 stated Resident 1 agreed to have CNA 1 and CNA 2 change his adult brief. CNA 2 stated Resident 1 started getting agitated when CNA 1 and CNA 2 started changing Resident 1's adult brief and hit CNA 1 and CNA 2. CNA 2 stated CNA 1 raised her left hand and "slapped" Resident 1 on the right side of his face. CNA 2 stated Resident 1 did not try to bite CNA 1. CNA 2 stated, "(CNA 1) did (hit Resident 1 on the right side of his face) out of anger. I saw (CNA 1's) expression (CNA 1) was really mad." CNA 2 stated CNA 1 told her, "(Resident 1's) like this (agitated during ADL care). Next time we'll close the door." CNA 2 stated Resident 1 got upset and started to cry. CNA 2 stated she noticed redness on Resident 1's right cheek. CNA 2 stated she reported CNA 1 hitting Resident 1 on the right side of his face to the Administrator on 8/26/25 at around 6 a.m. when the Administrator arrived at the facility. During an interview on 12/1/25 at 4:33 p.m. with Administrator, Administrator stated on 8/26/25 at 6 a.m., CNA 2 reported, while CNA 2 and CNA 1 were changing Resident 1's adult brief (on 8/26/25 at around 5:40 a.m.), Resident 1 grabbed CNA 1's hands, CNA 1 was in pain and pulled her hand (left) away and hit Resident 1 on the face (right side). Administrator stated CNA 2 used the word "hit" but CNA 2 "motioned like a slap." Administrator stated she went to see if CNA 1 was still in the building, but CNA 1 had already left. Administrator stated she informed LVN 1 (nurse assigned to Resident 1 on 8/25/25 night shift) of the physical abuse incident (CNA 1 hitting Resident 1 on the right side of his face on 8/26/25 at around 5:40 a.m.), to complete a skin assessment immediately, and to advise her of LVN 1's findings. Administrator stated she interviewed CNA 1 and CNA 2 twice (no dates provided). Administrator stated CNA 1 initially stated CNA 1 was pushing Resident 1's face away because Resident 1 was trying to bite CNA 1, but on CNA 1's second interview, CNA 1 did a demonstration of how she hit Resident 1's face, by replicating the action and she hit herself on the face with a "slapping motion." Administrator stated CNA 1 and Administrator "role played" the incident (CNA 1 hitting Resident 1 on the right side of his face on 8/26/25 at around 5:40 a.m.) in an empty room, and CNA 1 "hit" Administrator on the right side of her face with CNA 1's left hand. During a review of the facility's policy and procedure (P&P) titled, "Abuse, Neglect & Exploitation Policy," dated October 2022, the P&P indicated, "Residents have the right to be free from abuse, neglect, mistreatment, misappropriation of resident property, and exploitation." In violation of the above cited standards, the facility failed to ensure Resident 1 was free from physical abuse when Certified Nursing Assistant (CNA) 1 hit Resident 1 on the right side of his face while CNA 1 and CNA 2 were changing Resident 1's adult brief. This failure resulted in Resident 1 crying and redness on his face. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and represents a Class "A" citation.