Health inspection·March 12, 2026

California Code, Health, and Safety Code - HSC § 1418.91 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a patient 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. It was determined based on interview and record review, the facility failed to ensure an allegation of physical abuse involving Patient 1 and a facility staff member (Certified Nursing Assistant-CNA 2) was reported to the California Department of Public Health (CDPH - State Agency-Licensing and Certification Program) immediately or within 24 hours. The facility was aware of the alleged physical abuse on December 6, 2025. This failure delayed the investigation, placing Patient 1 at risk of further harm while at the facility. On December 8, 2025, CDPH received a report from the facility about an allegation of abuse involving a staff member (CNA 2) and Patient 1 which occurred on December 6, 2025.  The report indicated that a CNA placed a towel over the patient’s head and mouth. A review of Patient 1’s “Admission Record," indicated he was admitted to the facility on July 27, 2023, with diagnoses which included cerebral infarction (disrupted blood flow to the brain). A review of Patient 1’s “History and Physical Note,” dated November 21, 2024, indicated the patient’s decision-making capacity fluctuates. A review of Patient 1’s “SBAR (Situation, Background, Assessment, and Recommendation – a structure communication form that helps share information about the condition of a patient) Communication Form and Progress Note,” dated December 8, 2025, indicated the following: a. A CNA (CNA 1) reported an alleged abuse by another CNA (CNA 2) involving Patient 1 which occurred on December 6, 2025; and b. Patient 1 was assessed for injuries or wounds and was noted to have no issues. Patient 1 was calm and not in distress. Patient 1’s physician was notified. On December 11, 2025, at 11:36 a.m., during a telephone interview, CNA 1 stated the following: a. On December 6, 2025, between 8 p.m. to 9 p.m., he (CNA 1) was outside Patient 1’s room when he heard the patient grunting. CNA 1 stated he went to Patient 1’s room and found CNA 2 with the patient; b. He asked CNA 2 if she needed help and she (CNA 2) said yes. CNA 1 stated he saw CNA 2 throw a towel over Patient 1’s face and told the patient “be quiet”; c. He (CNA 1) removed the towel and told CNA 2 that Patient 1 would cooperate if you inform him (the patient) what you are going to do; d. He (CNA 1) told CNA 2 that she should not treat people in that manner; e. He (CNA 1) did not report the incident to a supervisor because he wanted to speak to the Director of Staff Development (DSD) and Nurse Educator himself; and f. He (CNA 1) reported the incident on December 8, 2025. He was initially confused, thinking he had 48 hours to report it, but clarified that abuse allegations should be reported immediately, within two to 24 hours. On December 11, 2025, at 1:11 p.m., during an interview, the DSD stated that staff were expected to report any observed or suspected abuse to their supervisor so that it could be reported to the Long-term Care Ombudsman, to CDPH, and so the facility could initiate an investigation. The DSD stated CNA 1 reported the abuse allegation involving Patient 1 on December 8, 2025, although the incident occurred on December 6, 2025. The DSD stated 48 hours had passed before CNA 1 reported the incident; and the DSD stated CNA 1 should have reported the incident immediately on December 6, 2025. On December 11, 2025, at 2:45 p.m., during an interview with the Director of Nursing (DON) and the Administrator (ADM), the ADM stated abuse allegations were supposed to be reported within two hours. The ADM stated CNA 1 should have reported the alleged abuse to the Registered Nurse or immediate supervisor when it happened and he (CNA 1) did not. A review of the facility document titled, “ELDER ABUSE DEPARTMENT OF JUSTICE TRAINING ACKNOWLEDGMENT,” signed by CNA 1 on November 3, 2025, indicated, “...I acknowledge that I have watched the Elder Abuse Training and understand compliance with the reporting requirement is mandatory. I have been notified of my obligations as mandated reporter...” A review of the facility’s policy and procedure titled, “Abuse Prevention Program,” dated January 2018, indicated, “...As part of the resident abuse prevention, the administration will...Investigate and report any allegations of abuse within timeframes as required by federal requirements...” Based on interview and record review, the facility failed to ensure an allegation of physical abuse involving Patient 1 and a CNA (CNA 2) was reported to CDPH immediately, or within 24 hours after the allegation was made. The facility reported the alleged abuse to CDPH on December 8, 2025 (Two days after the facility was aware of the alleged physical abuse), This failure delayed the investigation, placing Patient 1 at risk of further harm while at the facility. This violation had a direct or immediate relationship to the health, safety, or security of patients.