Health inspection·December 5, 2025

The following citation reflects the results of the California Department of Public Health during the investigation of one complaint. Complaint number: 2632222 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. The facility was found to be not in compliance with Title 22 Chapter 3 requirements for Skilled Nursing Facilities. State Class B citation 230022738 was issued for complaint number 2632222 at Health and Safety Code (HSC) §1418.91. §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 10/10/25 at 8:40 am, the Department conducted an unannounced visit to the facility to investigate staff treatment of residents. Certified Nurse Assistant (CNA) A stated she overheard CNA B tell Resident 3 to “Shut the F*** up. Get it together, when you got here you were male, now you’re female.” Staff failed to follow their abuse policy when they did not notify the California Department of Public Health (CDPH—a state agency that promoted the health, wellness, and safety of Californians), the local Ombudsman (a government official who protected resident rights), and the police department after an allegation of verbal abuse was made toward Resident 3. This failure caused a delay in investigating and placed Resident 3 at risk for continued verbal abuse. Findings: A review of the facility’s policies and procedures (P&P) titled, “Reporting Abuse to State Agencies and Other Entities/Individuals,” revised 1/1/17, indicated, all suspected allegations of abuse would be reported to CDPH, the local Ombudsman’s office, and the police department. A review of the facility’s P&P titled, “Protection of Residents During Abuse Investigation,” indicated, the facility would protect residents form further harm while investigating abuse allegations. A review of the “Admission Record,” dated 7/8/25, indicated that Resident 3 was admitted to the facility on 7/8/25 with the diagnoses of dysarthria following cerebral infarction (difficulty with speech after having a stroke), transsexualism (transgender, a person’s gender identity was different than their assigned birth gender), and aphasia (language disorder that affected the ability to speak). Resident 3 was her own responsible party (made own decisions). A review of Resident 3’s undated care plan (a written plan of resident goals and care instructions for facility staff) titled, “psychosocial well-being,” indicated, Resident 3 identified as a female. During a concurrent observation and interview on 10/10/25 at 9:52 am, CNA A, CNA A stated, “I overheard [CNA B] tell [Resident 3] “to shut the [F word] up. Get it together, when you got here you were male, now you’re female. I reported it to the charge nurse and the administrator, [CNA B] was very rude to [Resident 3], so I interrupted and put a stop to it.”   During an interview on 10/21/25 at 12:10 pm, with the administrator (Admin) and the Director of Nursing (DON), a copy of the 5-day abuse investigation report regarding allegations of staff witnessed verbal abuse was requested. Admin and DON both stated, “no one had ever reported this to us.” The Admin confirmed the allegation of verbal abuse was not reported to the required entities due to CNA A not reporting the allegation to the Admin or DON. In violation of the above cited standards, the facility failed to ensure that allegations of abuse were reported immediately to a supervisor and within two hours to the appropriate state and federal entities. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents and resulted in a B citation.