Other·November 19, 2025

Valencia Gardens Health Care 2636702 & 2637378 Class “B” Citation HSC 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. HSC 1418.91 (b) A failure to comply with the requirements of this section shall be a class “B” violation. California Code of Regulations, Title 22, Section 72521. Administrative Policies and Procedures. (a) Written administrative, management and personnel policies shall be established and implemented to govern the administration and management of the facility. Code of Federal Regulations, Title 42, 483.12 (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: 483.12 )c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides jurisdiction in long-term care facilities) in accordance with State law through established procedures. On October 8, 2025, at 8:30 a.m., an unannounced visit was conducted at the facility to investigate two complaints regarding an allegation of abuse involving Patient 1 and a Certified Nursing Assistant (CNA). It was determined that the facility failed to report Patient 1’s allegation of physical abuse to the California Department of Public Health (CDPH) immediately, or within 24 hours. Patient 1 alleged that a CNA punched her on the left side of her stomach. The facility was made aware of Patient 1’s allegation of physical abuse on October 6, 2025, but did not report the alleged incident to CDPH. This failure had the potential to result in delayed protection of Patient 1 and delayed in the implementation of corrective action, placing the patient at risk for further abuse. On October 8, 2025, Patient 1’s admission record was reviewed. Patient 1 was admitted into the facility on September 28, 2025, with diagnoses which included right femur fracture (broken thigh bone), congestive heart failure (heart can’t pump blood well), hypertension (high blood pressure), and atrial fibrillation (irregular rapid heartbeat). A review of the “History and Physical,” dated September 29, 2025, indicated Patient 1 had the capacity to make decisions. A review of the "SBAR (Situation, Background, Assessment, and Recommendation- a tool used to ensure clear, concise, and effective exchange of information between medical professionals)," dated October 6, 2025, at 7:06 a.m., indicated that Patient 1 reported to the Licensed Vocational Nurse (LVN) that during a transfer from bed to chair, a CNA was rough and punched her on the left side of her stomach. The LVN assessed Patient 1 and immediately reported the allegations to the Abuse Coordinator/Administrator. On October 8, 2025, at 10:09 a.m., the Abuse Coordinator/Administrator was interviewed. He stated he did not inform the Ombudsman or CDPH because the patient stated she did not feel abused; it was the patient's family member who was upset. He acknowledged that their policy required informing CDPH within 24 hours, which was not done. The facility policy and procedure titled, “Abuse, Neglect, Exploitation and Misappropriation Prevention Program,” undated, was reviewed. The policy indicated, “Reporting Allegations to the Administrator and Authorities…if resident abuse…the suspicion must be reported immediately to the administrator and to other officials according to state law…The administrator or the individual making the allegation immediately reports his or her suspicion to the following person or agencies…the state licensing/certification agency responsible for surveying/licensing the facility… local ombudsman…adult protective services…law enforcement…the residents attending physician… Immediately is defined as within two hours of an allegation involving abuse…or within 24 hours of an allegation that does not involve abuse…” Based on interview and record review, it was determined that the facility failed to report Patient 1’s allegation of physical abuse to the CDPH immediately, or within 24 hours. Patient 1 alleged that a CNA punched her on the left side of her stomach. The facility was made aware of Patient 1’s allegation of physical abuse on October 6, 2025, but did not report the alleged incident to CDPH. This violation had a direct or immediate relationship to health, safety, or security of the patients.