Health inspection·February 6, 2026

The following citation reflects the results of the California Department of Public Health during the investigation of complaint number 2711021. 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 California Health and Safety Code requirements for Skilled Nursing Facilities. A State Class B citation 230023017 was issued for complaint number 2711021 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 1/6/26 at 1:15 pm, the Department conducted an unannounced visit to the facility to investigate a resident abuse allegation. On 1/1/26, Resident 3 told Licensed Nurse (LN) C about being sexually abused. The Wellness and Recovery Director (WRD) received an email notification on 1/2/26 regarding Resident 3’s allegation. The facility failed to report the allegation of sexual abuse to the California Department of Public Health (CDPH), the police department, and to the local Ombudsman (an official who works to maintain resident rights). Findings:   A review of the facility’s policy and procedure (P&P) titled, “Client Abuse Prevention,” updated 10/14/24, indicated, “Staff will immediately and directly report to the Administrator any suspicions of client abuse, either witnessed or suspected.” The P&P indicated, “Due to the complexity of the clients being served by this facility (i.e., the seriously mentally ill), all reports of abuse will be initially screened by the Administrator or designee for the possibility of reality-based accusation (i.e., a flying dragon injured me, etc.,). All reality-based accusations will be immediately investigated and reported to officials in accordance with state law” (including the state licensing and certification agency [CDPH]).    A review of Resident 3’s “Admission Record,” dated 7/29/16, indicated, Resident 3 admitted to the facility on 7/29/16, with the diagnosis of schizoaffective disorder (schizophrenia, serious brain disorder that disrupted how a person thought, felt, or behaved, causing them to lose touch with reality and a mood disorder at the same time), bipolar type (a mood disorder that caused extreme mood swings). The courts appointed a conservator who made all decisions for the resident, and Resident 3 was conserved.   A review of Resident 3’s Annual Minimum Data Set (MDS, a resident assessment tool), dated 12/30/25, indicated staff conducted a Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgment status of the resident). Resident 3 scored a 15 on the assessment scale with a range of 0-15, which indicated intact memory, orientation, and judgment.   A review of Resident 3’s Annual MDS, dated 1/1/26, section E-Behaviors, indicated that Resident 3 experienced hallucinations (seeing or hearing things that were not there) and delusions (believing in something that was not true).   During a concurrent interview and record review on 1/8/26 at 11:33 am, with WRD, a review of the specific form used in California to report known or suspected abuse, dated 1/6/26 was reviewed. WRD confirmed the form included an email that WRD had sent to Resident 3’s Public Guardian’s (also known as the conservator) office on 1/2/26, indicating that a peer was having sex with Resident 3 without her consent and that the facility had investigated the allegation. WRD stated, “If I remember right, we were in a team meeting and I believe the nurse said it.” After the allegation was made, during the team meeting, regarding the peer on 1/2/26, me and the Administrator (ADMIN) investigated after the meeting.” WRD provided a “Social Services Note,” dated 1/2/26. WRD confirmed the “Social Services Note” indicated WRD received an email from a Licensed Nurse (LN) stating that Resident 3 made an allegation of assault and told the LN, “…she felt that a peer was coming into her room and having sex with her without her consent.” The Social Services Note indicated, “It is noted that her statement was demonstrably similar in nature to previous unverifiable accusations of others.”   During a concurrent interview and observation at the nurse’s station on 1/8/26, at 1:25 pm, Resident 3 calmly walked up to the nurse’s station and spoke at a normal rate and tone during introductions. Resident 3’s hands began to shake, and her speech became rapid and loud. Resident 3 stated, “No! I never said that, why would they keep saying that?” During Resident 3’s statement, her head moved from side to side, her voice trembled, and she looked at the floor. Staff asked Resident 3 who “they” were, and Resident 3 indicated LN C. Resident 3 stopped standing still, moved from side to side, and immediately ended the interview.   During a concurrent interview and record review on 1/8/26 at 1:59 pm, ADMIN provided an email dated 1/1/26. ADMIN confirmed that LN C sent an email to WRD and the Director of Nurses. ADMIN verified that the email stated, “She then began stating that people come into her room and rape her when she isn’t fully awake.” The words “rape” and “fully awake” contained quotation marks, indicating Resident 3 said those words while talking to LN C.   During an interview on 1/8/26 at 2:08 pm, LN C stated, “Resident 3 never told me that someone raped her. I sent a communication follow up to WRD.” LN C indicated that she did not send WRD an email and stated, “it was an internal communication, my concern is she has a fixation of becoming pregnant and was expressing a plan of becoming pregnant.”   During an interview on 1/9/26 at 10:23 am, ADMIN described what should happen when there is an allegation of sexual abuse. ADMIN stated, “We should take steps to keep residents safe, notify the police, DHS [social services, assisted with providing essential services], [CDPH, and the Ombudsman within two hours.” ADMIN confirmed Resident 3’s allegation of sexual abuse was not reported. In violation of the above cited standards, the facility failed to ensure that allegations of abuse were reported immediately to a supervisor and within twenty-four 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 is a B citation.