Health inspection·June 26, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review, the facility failed to implement their policy and procedure (P&P) on Abuse Prevention Program - Reporting for two of three sampled residents (Resident 1 and Resident 2) when: 1. The facility did not report an allegation of sexual abuse to the California Department of Public Health (CDPH), the Ombudsman (representatives advocating residents in long-term care facilities) and the local law enforcement (LLE) within 24 hours. 2. The facility did not complete a follow-up investigative report (FIR) within five working days. These failures had the potential to result in continuous sexual abuse and emotional distress for Resident 1 and Resident 2. Findings: 1. During a review of the SOC-341 (Report of Suspected Dependent Adult/Elder Abuse), dated 6/14/25, the SOC-341 indicated, (Activities Assistant [AA]) reported that (Resident 2) stated that (Resident 1) grabbed her breast. During a concurrent interview and record review on 6/26/25 at 1:39 p.m. with Director of Nursing (DON), the FAX Transmission Status (FTS), dated 6/16/25 was reviewed, the FTS indicated the SOC-341 was submitted to CDPH on 6/16/25 (two days after the allegation of sexual abuse on 6/14/25). DON stated there was no documentation to verify the SOC-341 was submitted to the Ombudsman and the LLE. DON stated the SOC-341 should have been submitted to CDPH, the Ombudsman and the LLE within 24 hours of the allegation of sexual abuse on 6/14/25. During a review of the facility's P&P titled, Abuse Prevention Program - Reporting, dated 2016, the P&P indicated, All reports of suspected and/or alleged sexual abuse must be immediately reported to the identified local law enforcement agency to be investigated as well as the immediate State Agency Report. Initial reporting of allegations: If an incident or allegation is considered reportable, the licensed nurse will make a report to California Department of Public Health and the Ombudsman within 24 hours. 2. During an interview on 6/26/25 at 1:39 p.m. with DON, DON stated she has not completed the FIR after the allegation of sexual abuse on 6/14/25. DON stated the FIR should have been submitted within five working days from 6/14/25 (by 6/20/25). Page 1 of 2 555517 555517 06/26/2025 Kern Valley Healthcare District Dp Snf 6412 Laurel Ave Lake Isabella, CA 93240

F 0609 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's P&P titled, Abuse Prevention Program - Reporting, dated 2016, the P&P indicated, After the report of the incident, a complete written report of the conclusion the investigation, including steps the facility has taken in response to the allegation, will be sent to California Department of Public Health within 5 business days. Residents Affected - Few 555517 Page 2 of 2