Other·October 8, 2025

The following reflects the findings of the California Department of Public Health during the investigation of Facility Reported Incident number 2594083 and Complaint Number 2590180. The inspection was limited to the specific facility reported incident and complaint investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for Facility Reported Incident number 2594083 and Complaint Number 2590180 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 8/18/25, an unannounced visit was conducted to the facility to investigate an allegation of misappropriation of property of Resident 1. Resident 1 was an 87-year-old female resident admitted to the facility on 4/12/25 with diagnoses of morbid (severe) obesity (large body mass), Type 2 Diabetes (abnormal sugar level in the blood), Muscle weakness, and Anxiety disorder (feelings of excessive worry). Based on interview and record review, the facility failed to follow its policy and procedure for one of three sampled residents (Resident 1) when an alleged misappropriation of resident property was not reported to the Department of Public Health (CDPH) within 24 hours. This failure resulted in a delay in the investigation. Findings: During a review of the "Theft & Loss Form" (TLF - facility form used to document loss of items) dated 8/10/25, the TLF indicated "Date & Time of Report. . .8/10/25. . .Description of missing items. . .money 600 dollars. . ." During a review of Resident 1's "Progress Notes" (PN) dated 8/10/25 at 2:32 p.m., the PN indicated, "CNA [Certified Nursing Assistant] approached writer and stated that the resident [1] said she was missing personal belongings. Upon arrival RN [registered nurse] supervisor was in resident's room helping look for belongings. Writer called daughter [daughter's name] and notified. The inventory sheet was reviewed. Resident filled out theft and loss form and turned into SS [Social Services]. SS aware." During a review of the "Report of Suspected Dependent Adult/Elder Abuse (SOC 341)," dated 8/18/25 (seven days after the facility was made aware), the SOC 341 indicated, "Resident [1] report of alleged allegation of missing money. Resident [1] has a BIMS [Brief Interview for Mental Status-used to assess cognitive function] score of 15 on a scale of 0-15 [a BIMS score of 13 to 15 means cognitively intact]." During an interview on 8/18/25 at 3:46 p.m. with Social Service Director (SSD), SSD stated when the $600 was reported missing, the daughter did not want to call the police. SSD stated the incident should have been reported to the CDPH. During an interview on 8/18/25 at 4:41 p.m. with Administrator, Administrator stated on 8/10/25, Resident 1 reported she was missing $600, and an investigation was started. Administrator stated the missing $600 was not reported to the CDPH because the amount of money missing was not adding up during the investigation. Administrator stated it should have been reported to CDPH within 24 hours. During a review of the facility policy and procedure (P&P) titled, "Theft/Loss Prevention" dated 8/2020, the P&P indicated, "When an alleged or suspected case of misappropriation of resident property is reported, the Administrator, or designee, notifies the following persons or agencies within twenty-four (24) hours of such incident. . .Department of Public Health." In violation of the above cited statute, the facility failed to report the allegation of misappropriation of property to the CDPH. This failure resulted in the delay of the investigation. This violation had a direct or immediate relationship to the health, safety, or security of residents and constitutes a Class "B" citation.