Health inspection·January 13, 2026

The following reflects the findings of the California Department of Public Health (CDPH) during the investigation of a facility reported incident number 2686768. A Class B Citation was written. §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. §483.12(a) The facility must- §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; §483.40 Behavioral health services. Each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders. 22 CCR § 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. On 12/9/2025, CDPH made an unannounced visit to the facility to investigate an allegation regarding a resident-to-resident abuse when Resident 4 sexually assaulted Resident 3 and then Resident 3 punched Resident 4, without any resulting injuries. CPDH received the abuse allegation from the facility on 12/8/2026 at 8 AM. Based on interview, and record review, the facility failed to: 1. Protect Resident 3 from inappropriate sexual contact by Resident 4, in violation of its policy and procedure titled "Abuse Prohibition" (last reviewed 02/23/2021). The facility was aware that Resident 3 was unable to defend against a sexual assault. 2. Implement effective interventions to manage Resident 4's behaviors, which included a history of poor personal boundaries and inappropriate physical contact with residents and staff. These deficient practices placed Resident 3 and other residents at risk for sexual abuse and psychosocial harm. During a review of Resident 4's admission record (face sheet - a document containing demographic and diagnostic information) indicated Resident 4 was admitted to the facility on 7/12/2017 with the following diagnoses: paranoid schizophrenia (a serious mental disorder characterized by prominent symptoms like intense paranoia, delusions , and hallucinations). During a review of Resident 4's Care Plan (CP - a guideline for nurses to help them create and achieve a solid plan of action in the treatment of a patient) initiated on 7/13/2017 with revision dates of 4/30/2021, 2/07/2025, and 7/31/2025, indicated, Resident 4 had demonstrated repeated bizarre or inappropriate social behaviors related to poor boundaries as evidenced by incidents of standing too close, hovering, or touching others. The CP interventions included to encourage psych/behavioral health consultation, participate in Special Treatment Program for management of physical behaviors, engage in 1:1 (one to one - a staff provides dedicated, focused attention and assistance to a single individual, ensuring their needs and well-being are met with personalized support) counseling focused on social skills to encourage appropriate social interactions with peers/staff. During a review of Resident 4's Behavior Monthly Summary for 2024 for behavior manifestation of intense staring, standing too close, intrusiveness as evidenced by poor boundaries indicated Resident 4 had the following number of episodes during the day shift (7 AM to 3 PM) from 1/2024 through 12/2024: January=61 February=50 March=58 April=58 May=61 June=63 July=63 August=56 September=63 October=62 November=62 December=28 The Behavior Monthly Summary for 2024 indicated a total 684 episodes for behavior manifestation of intense staring, standing too close, intrusiveness as evidenced by poor boundaries. During a review of Resident 4's Behavior Monthly Summary for 2024 for behavior manifestation of masturbating in public and inappropriate touching indicated, Resident 4 had the following number of episodes during the day shift (7 AM to 3 PM) from 1/2024 through 12/2024: January=23 February=23 March=29 April=30 May=38 June=39 July=36 August=41 September=36 October=46 November=48 December=6 The Behavior Monthly Summary for 2024 indicated a total 395 episodes for behavior manifestation of intense staring, standing too close, intrusiveness as evidenced by poor boundaries. During a review of Resident 4's history and physical (H&P - a physician's complete patient examination) dated 7/24/2025 indicated, Resident 4 had the diagnosis of paranoid schizophrenia and is under a conservatorship (a legal process for adults with severe mental illness who are gravely disabled; they cannot provide for their basic needs and manage their medical treatment, and placement to facilities due to their illness). During a review of Resident 4's Psychotherapy Progress Notes (a standardized tool used by psychologists to record resident's mental and emotional state, behavior and any changes in their condition, to inform care planning and treatment) dated 10/06/2025, indicated, at the time of consultation, Resident 4 was experiencing paranoia, anxiety, intrusiveness, impulsiveness, had delusional thinking, auditory hallucinations, and was disoriented. During a review of Resident 4's Psychotherapy Progress Notes dated 10/24/2025 indicated, Resident 4 reported remembering previous discussions about the importance of maintaining physical boundaries with the other residents. The Psychotherapy Progress Notes interventions indicated, "Pt (Patient-Resident 4) was able to engage with this writer re (regarding) maintaining appropriate boundaries." During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool) dated 10/31/2025, indicated, Resident 4 has an intact cognition (a person's thinking and reasoning abilities are functioning properly and are not significantly impaired). During a review of Resident 4's Nursing Progress Notes dated 11/25/2025 at 12:09 PM, Resident 4 was "grabbing others...but redirected to walk..." During a review of Resident 4's Nursing Progress Notes dated 12/06/2025 at 8:29 AM indicated, Resident 4 went inside a shared restroom and touched a male peer without consent while urinating. The male peer slapped Resident 4 and followed Resident 4 to his room to continue the fight. Resident 4's roommate (Resident 3) then reported to PC (patient coordinator) who separated and redirected the residents to their room. Resident 4 was placed on a 1:1 monitoring. During a review of Resident 4's Room Transfer form dated 12/06/2025 at 2:50 PM, the form indicated Resident 4 was transferred from Room A to Room B due to peer incident (with resident 3). During a review of Resident 4's CP initiated on 12/07/2025 indicated, Resident 4 had poor personal boundaries and inappropriate physical contact with peers, increasing risk for peer conflict and safety concerns. The CP's interventions included the following, staff will teach resident proper space rules and explain why touching others without consent is unsafe and unacceptable. Staff to provide firm, consistent redirection when boundary issues occur. During a review of Resident 4's Nursing Progress Notes dated 12/08/2025 at 10:10 PM, indicated Resident 4 had "verbal expressions of distress up to 5 days a week." The progress notes also indicated Resident 4 was being monitored for "intrusive behavior, needed multiple redirections to focus on self and treatment plan and encouraged to maintain proper boundaries with peers." The Nursing Progress Notes did not indicate Resident 4 was on 1:1 monitoring and supervision. During a review of Resident 4's Nursing Progress Notes dated 12/09/2025 at 6:21 AM, indicated Resident 4 remained on every 15-minute checks for intrusive behavior. The Nursing Progress Notes did not indicate Resident 4 was on 1:1 monitoring and supervision. During a review of Resident 3's admission record indicated Resident 3 was admitted to the facility on 5/05/2022 with the following diagnoses: paranoid schizophrenia and hallucinations. During a review of Resident 3's H&P dated 5/28/2025 indicated, Resident 3 had a diagnosis of paranoid schizophrenia and was under a conservatorship. During a review of Resident 3's MDS dated 8/20/2025, indicated, Resident 3 had intact cognition. During a review of Resident 3's Psychotherapy Progress Notes dated 12/07/2025 indicated, Resident 3's chief complaint was that "[Resident 4] shouldn't be touching me." Resident 3 reported understanding concerns regarding Resident 4's inappropriate boundaries such as touching. During a review of Resident 3's CP initiated on 12/07/2025 on risk for emotional distress and physical harm. The CP interventions included staff will provide reassurance, validation of feelings, and reinforce staff availability for protection and support. During a review of Resident 3's Interdisciplinary Care Conference (ICC - collaborative meetings where healthcare professionals-such as doctors, nurses, therapists, and social workers-coordinate care for complex patients, developing unified treatment plans to improve outcomes, reduce hospital stays, and enhance communication) notes dated 12/08/2025 indicated, "while (Resident 3) was urinating in the shared bathroom, [Resident 4] attempted to touch Resident 3's private area without permission. Resident 3 "felt scared and uncomfortable...or threatened...[Resident 3] reacted by hitting [Resident 4] to protect [Resident 3] instead of calling for staff support." During a review of facility undated In-Service Education (a professional development for workers aimed to enhance their skills, knowledge, and competence to improve job performance) titled "Sexual Trauma, Physical Abuse, Monitoring and Intervention" indicated, a resident-to-resident aggression is also abuse and requires staff intervention. One of the in-service lesson plan topics indicated "review past behaviors of residents who are at risk for abusing others." During an interview on 12/09/2025 at 11:57 AM Resident 3 stated that on 12/06/2025, he was taking a "piss (urinating) in the bathroom (restroom) when Resident 4 opened the door to the bathroom without permission. Resident 3 stated he asked Resident 4 what Resident 4 was doing in the bathroom but Resident 4 did not answer him. Resident 3 stated he was talking with Resident 4 but could not remember what else happened after that. When asked if Resident 4 did anything inappropriate to him (Resident 3), Resident 3 stated "we were talking then we have a fight with closed fist. I hit him first on the face." Resident 3 stated hitting Resident 4 with his right fist "because [Resident 4] was in the bathroom and I got there first." During an interview on 12/09/2025 at 2:04 PM with Resident 5, Program Counselor (PC) 3 translated for Resident 5's language of choice. Resident 5 was Resident 4's roommate. Resident 5 stated "[Resident 4] likes touching people a lot." During an interview on 12/09/2025 at 2:14 PM, Certified Nurse's Aide (CNA) 1 stated [Resident 4] "likes to touch residents like their top-shoulders, arms, without their consent." CNA 1 stated Resident 3 may have felt anger and violated when Resident 4 allegedly touched Resident 3 inappropriately and without permission. During an interview on 12/09/2025 at 2:53 PM, Licensed Vocational Nurse (LVN) 1 stated that on 12/06/2025, PC 2 reported to LVN 1 about a physical altercation between Resident 3 and Resident 4. LVN 1 stated that during an interview with Resident 4, Resident 4 said, "I went to the bathroom, I touched him (Resident 3)...I touched him...I touched him..." repeatedly, but Resident 4 did not state which part of Resident 3's body Resident 4 touched. LVN 1 stated both residents were separated, Resident 4's room was changed from Room A to Room B on the same day the alleged physical altercation happened. LVN 1 also stated that during the same interview, Resident 3 told LVN 1, "[Resident 4] came in there bathroom and tried to touch my penis." LVN 1 stated that Resident 3 slapped Resident 4 on the face when Resident 4 tried to touch his penis. LVN 1 stated the bathroom is shared by residents in rooms on either sides. LVN 1 also stated PC 2 told LVN 1 that PC 2 witnessed the physical altercation between Resident 3 and Resident 4 where Resident 4 was in bed and Resident 3 stood over Resident 4 with arms stretched. LVN 1 stated Resident 4 was cowering (to lower the head or body in fear, often while moving backwards) and covering his head and face with both arms covering both as if to protect himself from a possible physical altercation from Resident 3. LVN 1 also stated PC 2 told LVN 1 that PC 2 heard Resident 3 angrily ask Resident 4, "what are doing in the bathroom?" when Resident 3 was using the bathroom, but Resident 4 did not answer Resident 3. LVN 1 described Resident 4's behavior towards other residents as "intrusive...likes to touch people...doesn't understand boundaries...this has been [Resident 4's] behavior since he's been here. When LVN 1 was asked what has the staff done to ensure the safety of the other residents when Resident has a history of intrusiveness, LVN 1 answered "we counsel...redirect to a program or tv (television) room, supervise [Resident 4] ... CNAs are standing in the hallways, when they see [Resident 4] touching someone, CNAs redirect him." LVN 1 stated Resident 3 may have felt disrespected, anger and violated when Resident 4 allegedly touched Resident 3 inappropriately and without permission. On 12/9/2025 at 4:56 PM, Resident 4's psychologist was contacted with no response. A voice mail was left for the psychologist to call back the author. During a phone interview on 12/10/2025 at 9:59 AM, PC 2 stated one of the residents got PC 2's attention to go to Room A (Resident 4's room) due to an alleged physical altercation. PC 2 stated PC 2 witnessed Resident 4 sitting on the bed with '[Resident 4's] hands up like a defensive move, Resident 3 was standing up in front of Resident 4." PC 2 added, Resident 3 angrily said to Resident 4 "don't try to touch me like that." PC 2 also stated Resident 3 asked Resident 4 to back off and Resident 4 immediately complied. PC 2 stated Resident 3 then turned around to face PC 2 and to told PC 2, "[Resident 4] tried to touch me on my private part," when PC 2 asked Resident 3 if that was the only thing that happened, Resident 3 said "yes." PC 2 stated Resident 3 continued to say that Resident 3 was using the bathroom when Resident 4 entered the bathroom without permission. PC 2 stated that Resident 3 slapped Resident 4's hand because, "it was close to [Resident 3's] private part." PC 2 said PC 2 assumed the reason why Resident 3 walked into Resident 4's room "after the bathroom incident was to tell [Resident 4] to back off and to ask Resident 4 why [Resident 4] tried to touch Resident 3's private part." PC 2 described Resident 4's behavior towards other residents as "very disoriented...he touches everything, people...not just men or women, it's both...you know how a blind man touches something, [Resident 4] is like that." PC 2 was asked what has the staff done to ensure the other residents' safety and PC 2 stated "there is always a CNA in the hallway or the tv room...we know [Resident 4] has problems with touching, it's not gonna stop no matter how much we talk to [Resident 4]...we redirect...we tried to use words like "safe hands" meaning to keep [Resident 4's] hand to self." PC 2 stated Resident 3 "felt definitely disrespected" when Resident 4 allegedly touched Resident 3 inappropriately and without permission. During an interview on 12/10/2025 at 1:23 PM, Registered Nurse Supervisor (RNS) 1 stated Resident 4's behavior towards other residents is that "[Resident 4] always touching stuff and other residents w