Health inspection·July 1, 2025

42 C.F.R. §483.12 Freedom from Abuse, Neglect, and Exploitation  The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident’s medical symptoms.  (a) The facility must—  (1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;  (b) The facility must develop and implement written policies and procedures that:  (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,  (2) Establish policies and procedures to investigate any such allegations, and  Title 22 California Code of Regulations §72315. Nursing Service - Patient Care. (b)Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. California Code of Regulations, Title 22, §72527. Licensee - Patient Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (10) To be free from mental and physical abuse. California Code of Regulations, Title 22, § 72311. Nursing Service - General. (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B)Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time-limited. (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. California Code of Regulations, Title 22, §72523. Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 5/23/2025, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a facility reported incident regarding resident sexual abuse. On 5/22/25 at approximately 8:13 PM, Resident 2 went inside Resident 1’s room while Resident 1 (who did not have the capacity to consent for sexual activities) was laying down in bed and Resident 2 pulled out his genitals. Resident 1 told Resident 2 to stop, Resident 2 was masturbating in front of Resident 1 and got on top of Resident 1 while Resident 1 was laying down. Resident 2 touched and sucked on Resident 1’s breasts. Resident 1 told Resident 2 to stop, and Resident 2 did not stop. The facility failed to: 1. Notify attending licensed healthcare practitioners, the administration, and Resident 1’s Public Guardian, that Resident 1 and Resident 2 engaged in a prior sexual relationship. 2. Identify, develop, and implement care plans for Resident 1 and Resident 2 to engage in sexual activity in the facility. 3. Develop, review, evaluate, and update care plans for Resident 1 and Resident 2 when their relationship ended. 4. Prevent sexual abuse and ensure Resident 1 was free from sexual abuse from Resident 2, who had a history of exchanging money for sex while residing at the facility, when Resident 2 performed various non-consensual sexual acts toward Resident 1 on 5/22/2025. 5. Implement its policies and procedures titled “Abuse Prohibition Administrative Policies”, “Identifying Sexual Abuse and Capacity to Consent”, and “Abuse, Neglect, Exploitation, or Misappropriation – Reporting and Investigation”. As a result of these failures, Resident 1 experienced sexual abuse from Resident 2 while under the care of the facility and she (Resident 1) felt like an “Object,” and like “I don’t matter.” During a review of Resident 1’s Admission Record, the Admission Record indicated the facility originally admitted Resident 1, a 36-year-old female, on 4/8/2020 and readmitted on 1/5/2022. The Admission Record indicated the resident had diagnoses that included paranoid schizophrenia. During a review of Resident 1’s History and Physical (H&P) dated 10/30/2024, indicated Resident 1 could not make her own decisions but could make needs known. The H&P indicated Resident 1 can understand and is able to be understood. During a review of Resident 1’s Authorization to Detain and Treat Conservatee, dated 4/26/2024, indicated Resident 1 was conserved from 3/18/2024 through 2/28/2025. The court granted the Office of the Public Guardian authority to require Resident 1 to receive any treatment related specifically to remedying or preventing the recurrence of the resident’s grave disability and to require the resident to be treated with psychotropic medication. The authorization was only for the treatment of the mental health disorder responsible for the resident’s condition of grave disability. The court indicated that if any other treatment would be necessary, it should be obtained from the resident. The court also granted power# 12 for “Non-invasive care and treatment of chronic medical conditions in conservatee's medical history including: seizure disorder, asthma. Hypertension, anemia, blood draws, and gastro reflux disease.” During a review of Resident 1’s Minute Order (a brief, written document that summarizes a judge's decision during a court hearing or proceeding), dated 2/24/2025, indicated a Guardian was reappointed as Resident 1’s conservator until 2/28/2026 based on the court’s finding that the resident remained gravely disabled as a result of a mental disorder. During a review of Resident 1’s Minimum Data Set (MDS, a resident assessment tool) dated 4/22/2025, Resident 1 had potential indicators of psychosis (loss of touch with reality) and delusions (misconceptions or beliefs, contrary to reality). During a review of Resident 1’s Care Plan Report dated 5/22/2025, indicated Resident 1 was at risk to exhibit psychosocial distress related to an abuse allegation. The Care Plan Report indicated “Resident reported to staff experiencing a sexual assault by a male peer. ?She stated, Resident (unidentified) touched me, sucked my breast, and hugged me while I was saying “stop” and “no.” During a review of Resident 1’s Nurses Progress Note dated 5/22/2025, timed 8:13 PM, indicated Resident 2 entered Resident 1’s room and pushed himself on Resident 1, digging his hands and face into Resident 1’s breasts. The Nurse’s Progress Note indicated Resident 1 expressed Resident 1 was uncomfortable and asked Resident 2 to stop, and Resident 2 refused. During a review of Resident 1’s Nurses Progress Notes dated 5/22/2025 at 11:06 PM, indicated Resident 1 went to the nurse’s station (on 5/22/2025) to report a sexual assault by a male peer (Resident 2). The Nurse’s Progress Notes indicated Resident 1 did not want Resident 2 to enter Resident 1’s room again. The Nurse’s Progress Notes indicated Resident 1 was encouraged to “Alert staff and get help if any man came to her room without her consensus.” During a review of Resident 1’s Social Service Progress Note dated 5/23/2025 at 1:30 PM, indicated the DON met with Resident 1 and “Resident (Resident 1) reported that a male resident (Resident 2) entered the room, and although she (Resident 1) told him (Resident 2) to leave, he (Resident 2) proceeded to lie on top of her (Resident 1). The Social Service Progress Note indicated Resident?1 disclosed that she (Resident 1) had been in a brief relationship "One week," (unidentified date) with a male resident (Resident 2). The Social Service Progress Note indicated the local police department interviewed the resident (Resident 1). During a review of Resident 1’s Progress Note dated 5/28/2025 at 5:21 PM, it indicated that Resident 1 expressed emotional distress at the time of the incident. She consistently indicated that she did not consent to the physical contact. She stated that she feels safe but remains cautious when Resident 2 is nearby. The mental status evaluation of Resident 1 indicated: “Mood is anxious, and affect is appropriate. The thought process is linear, and cognition appears intact. Impulse control, insight, and judgment are partially impaired. The patient has a prior history of engaging in consensual sexual activity with the other resident; however, she currently lacks the capacity to consent due to her conservatorship and underlying psychiatric condition.” During a review of Resident 2’s Admission Record indicated the facility admitted Resident 2, a fifty-four-year-old male, on 9/17/2024, with diagnoses that included schizophrenia and personal history of traumatic brain injury (TBI-a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head). During a review of Resident 2’s History and Physical dated 10/30/2024 indicated Resident 2 did not have the capacity to make his own decisions but could make needs known. During a review of Resident 2’s General Progress Notes dated 12/14/2024 timed at 1:41 PM, written by the Program Counselor indicated Resident 2 was sexually active with different residents (unidentified) and would give money. During a review of Resident 2’s Social Service Progress Note dated 5/23/2025 at 11:52 AM, the local police department went to speak with Resident 2 on 5/23/2025 at 9:15 am, and did not question Resident 2 because Resident 2 was asleep. During a review of Resident 2’s Nurses Progress Note dated 5/23/2025 at 12:34 PM, indicated Resident 2 stated "I touched her (Resident 1) breast," (on 5/22/2025). The Nurses Progress Note indicated Resident 2 was asked where he (Resident 2) touched Resident 1 and Resident 2 replied, "I went to her (Resident 1) room, and I touched her (Resident 1) breast." The Nurses Progress Note indicated Resident 2 stated Resident 1 was in her bed and "She (Resident 1) told me to stop then I left the room." The Nurses Progress Note indicated Resident 2 denied pulling down his pants and when asked what would happen if the resident (Resident 2) touched someone without consent, the resident replied, "I will be in trouble." During a review of Resident 2’s Nurses Progress Note dated 5/23/2025 timed 12:45 AM, the Nurses Progress Note indicated Resident 2 reported he (Resident 2) went to Resident 1’s room and touched the resident’s (Resident 1) breast “Because she is hot.” During an observation and interview on 5/23/2025 at 8:33 am, Resident 2 was observed asleep in his room not able to be interviewed. During an interview on 5/23/2025 at 1:27 PM, Resident 2 stated he (Resident 2) touched Resident 1’s breasts on 5/22/2025 evening (unidentified time). Resident 2 stated Resident 1 did not give him (Resident 2) permission to touch Resident 1’s breasts. During an interview on 5/23/2025 at 1:36 PM Registered Nurse (RN ) 1, stated he (RN1) saw Resident 2 going in and out of Resident 1’s room on the evening of 5/22/2025 (unspecified time prior to 8:13 PM). RN 1 stated he (RN1) notified the ADM and the psychiatrist (a medical doctor who specializes in the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders) once Resident 1 informed him?(RN1) Resident 2 allegedly sexually assaulted her (Resident 1) on 5/22/2025 at 8:13 PM. During an interview on 5/23/2025 at 2:02 PM Resident 3 (Resident 1’s roommate), stated she (Resident 3) was in the room on 5/22/2025, in the evening, when she (Resident 3) heard Resident 1 say “stop it.” During an interview on 5/23/2025 at 2:16 PM, Certified Nursing Assistant (CNA), stated Resident 1 and Resident 2 were in a relationship in the past (unidentified time and date) and she (CNA1) observed Resident 1 and Resident 2 undressed and having sex. CNA1 stated she (CNA1) could not tell how long ago Resident 1, and Resident 2 had sex. During an interview on 5/27/2025 at 8:42 AM, with PG 1 indicated that public guardians do not typically consent to their conservatees engaging sexual activity. During an interview on 5/27/2025 at 9:15 AM Public Guardian (PG) 3 for Resident 1, stated that she had been Resident 1’s guardian since October 2024. PG 3 was not aware of Resident 1 having prior sexual encounters at the facility. PG 3 had not received notification of Resident 1 engaging in sexual activity. During an observation and interview on 5/27/2025 at 12:19 PM with Resident 1, Resident 1 stated she (Resident 1) was assaulted on 5/22/2025. She (Resident 1) heard a knock on her door. Resident 1 stated she (Resident 1) saw Resident 2 and told him “Hell no” and “Go away.” Resident 1 stated Resident 2 went into her room where Resident 1 was lying down, and Resident 2 pulled out his genitals. Resident 1 stated she (Resident 1) told Resident 2 to stop, and Resident 2 was “Jerking off in front of me and got on top of me while I was laying down and was playing with my breasts.” ?Resident 1 stated she (Resident 1) kept asking Resident 2 to stop but Resident 2 did not stop. ?Resident 1 stated she (Resident 1) did not consent for Resident 2 to touch her (Resident 1). Resident 1 stated when Resident 2 touched her and did not stop, she (Resident 1) felt like an “Object” and “Like I don’t matter.” During a telephone interview on 5/27/2025 at 1:12 PM, the Nurse Practitioner, who was covering for the Medical Director, he (Nurse Practitioner) was not familiar with the sexual activities of the facility and that the residents (in general) who were not capable of making decisions were not supposed to engage in sexual activities. During a concurrent interview and record review on 5/27/2025 at 1:32 PM with the DON, Resident 2’s General Progress Notes, dated 12/14/2024, timed at 1:41 PM were reviewed. The DON stated the General Progress Notes indicated Resident 2 was sexually active with different residents (unidentified) and would give money. The DON stated she (DON) did not know and was not aware Resident 2 would give and receive “money for sex.” The DON stated she (DON) and the facility did not investigate the allegations of Resident 2 receiving money for sex. During an interview on 5/27/2025 at 1:45 PM , the Program Counselor stated he (Program Counselor) worked with Resident 2 and he (Program Counselor) was familiar with Resident 2. The Program Counselor stated he (Program Counselor) was the writer of Resident 2’s General Progress Notes, dated 12/14/2024, timed at 1:41 PM. The Program Counselor stated Resident 2 told him on 12/14/2024 at 1:41 PM, that he (Resident 2) would give and receive money for sexual favors from Resident 1 and other residents (could not remember which residents and how much money). The Program Counselor stated he (Program Counselor) reported what Resident 2 told him regarding the money exchange for sex to a director (unidentified) who no longer worked at the facility. The Program Counselor stated he (Program Counselor) was supposed to also report the money exchange for sex to the DON and to the ADM as another form of abuse exploitation (taking advantage of a resident for personal g