Health inspection·November 14, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow policy and procedure in reporting allegations of abuse for one of three sampled residents (Resident 2), when Resident 2 reported an allegation of physical and sexual abuse to the Psychologist and this was not reported immediately after the allegation was made to the required designee's and authorities, including the state survey agency (CDPH, California Department of Public Health). This failure resulted in the delay of the investigation process and the potential in leaving Resident 2 and other residents unprotected from abuse.Findings:During a review of Resident 2's Face sheet (demographics), dated 9/23/2025, the Face sheet indicated Resident 2 was admitted on [DATE], with a diagnosis of Schizoaffective disorder, bipolar type (mental health condition that combines schizophrenia and mood disorder symptoms).During a review of Resident 2's Quarterly Psychology Progress Note (QPPN), dated 9/2/2025, completed by the Psychologist, the progress note indicated, Resident 2 discussed about being beaten and raped by white people and claims the same incident occurred. Further review of the progress note indicated, Resident 2's story did not change.During an interview on 9/26/2025 at 9:09 a.m. with Standards and Compliance (SC), SC confirmed there was no incident report for Resident 2 regarding the allegation of sexual and physical abuse on 9/2/2025. SC confirmed, this was not reported to the State Survey Agency.During an interview on 9/26/2025 at 9:35 a.m. with the Psychologist Director (PsyD), PsyD stated he reviewed the Psychologist progress note for Resident 2 and confirmed the alleged sexual and physical abuse on 9/2/2025 was not reported. PsyD stated it should have been reported and followed up on.During an interview on 9/26/2025 at 10:28 a.m. with the Unit Supervisor (US), US stated she was not notified of Resident 2's allegation of sexual and physical abuse on 9/2/2025.During an interview on 9/26/2025 at 2:00 p.m. with the Program VI Director (PD), PD reviewed her files and stated she did not find any reports of Resident 2 alleging sexual and physical abuse on 9/2/2025. PD further stated once staff is notified of any alleged abuse, the staff member needed to complete an SOC 341 (A report used to document and report any suspected physical, sexual, financial abuse and neglect) and notify program management. PD stated all cases of alleged abuse are reported regardless of mental disorders.During an interview on 9/30/2025 at 2:39 p.m. with the Psychologist, the Psychologist confirmed on 9/2/2025 Resident 2 disclosed previous sexual and physical abuse. The Psychologist reviewed prior progress notes and found no mention of prior reporting of sexual and physical abuse. The Psychologist confirmed she did not report this to her supervisor, program management or standards and compliance.The Psychologist stated she didn't think an allegation of abuse was reported if it happened in a different facility. The Psychologist stated she should have created an incident report and reported the abuse allegation internally.During a review of the facility's policy and procedure (P&P) titled, Reporting Patient Abuse and Neglect, dated 5/7/2025, the P&P indicated, When an employee receives an allegation of abuse from a patient that is reported to have occurred prior to admission to [facility name] . or Page 1 of 3 555731 555731 11/14/2025 Dept of State Hospitals - Metropolitan Snf 11401 South Bloomfield Avenue Norwalk, CA 90650

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few while being confined in a local custody facility, they shall immediately: notify a physician in all cases of any suspected physical . complete a report of Suspected Dependent Adult/Elder Abuse (Form SOC 341) . if an allegation was never reported . forward a courtesy report . report to California Department of Public Health. verify notifications have been made; to include Program Management, Standards Compliance, and the Office of Law Enforcement Support.During a review of the facility's policy and procedure (P&P) titled, Rape or Sexual Assault of Elder/Dependent Adult (Actual or Alleged), dated 4/1/2025, the P&P indicated, Procedures to be implemented immediately upon the discovery of a case of alleged sexual assault. The unit supervisor or designee will notify the patient's Program Director or designee and the Department of Protective Services (DPS) immediately, and complete form SOC-341. An incident report must be prepared by the reporting treatment unit. is required to report the facts to a local law enforcement agency. 555731 Page 2 of 3 555731 11/14/2025 Dept of State Hospitals - Metropolitan Snf 11401 South Bloomfield Avenue Norwalk, CA 90650

F 0940 Develop, implement, and/or maintain an effective training program for all new and existing staff members. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to complete an annual performance evaluation on Psychiatric Technician (PT 1) for eight years. This failure had the potential to prevent PT 1 and other employees from acquiring the necessary skills to meet their job expectations.Findings:During a concurrent interview and record review on 9/23/2025 at 2:15 p.m. with the Staff Services Manager HR (SSMHR), PT 1's employee file was reviewed. PT 1 was hired in November 2017 and never had an employee performance evaluation completed. SSMHR stated there should have been eight employee performance evaluations for PT 1 and it was not normal for the evaluations to be missing. SSMHR further stated the performance evaluations were to be completed annually.During an interview on 9/25/2025 at 11:37 a.m. with the Unit Supervisor (US), US confirmed she did not complete any performance evaluations for PT 1. US stated, it was an oversight. US further stated performance evaluations were necessary to provide feedback and education to an employee.During a review of the facility's policy and procedure (P&P) titled, Performance Appraisal and Employee Development, dated 11/28/2023, the P&P indicated, All supervisors and managers will prepare Form 638 (Performance Appraisal Summary) on employees assigned to them at least once each year. Residents Affected - Few 555731 Page 3 of 3