Health inspection·April 21, 2026

The following reflects the findings of the California Department of Public Health (CDPH) during the investigation of a facility reported incident and complaint number 2801309 & 2799996. 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; 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 3/24/2026, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility reported incident and complaint regarding financial abuse on Resident 1 by Licensed Vocational Nurse (LVN) 1 during the month of 2/2026. The facility failed to protect the rights of Resident 1 to be free from financial abuse according to facility's policy and procedures (P&P) titled, "Gifts, Gratuities, and Payments," reviewed 3/2025, when Licensed Vocational Nurse (LVN) 1 over the course of three days, made several purchases including reserving a hotel room for LVN 1 and charged Resident 1's credit card during the month of 2/2026. Resident 1 did not authorize the purchases. As a result, Resident 1 was upset because LVN 1 charged $1213.02 to Resident 1's credit card without the resident's permission. A review of Resident 1's Admission Record indicated the facility admitted Resident 1 on 9/3/2025, with diagnoses including but not limited to dementia (a progressive state of decline in mental abilities), atrial fibrillation (an irregular heartbeat that can lead to blood clots and increases the risk of stroke and other heart complications) and Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities). A review of Resident 1's Quarterly Minimum Data Set (MDS - a resident assessment tool) dated 12/11/2025 indicated Resident 1 had severely impaired cognition (ability to think, understand, and reason) and was usually able to make self-understood, and was usually able to understand others. The MDS indicated the resident required substantial assistance with toileting hygiene, bathing and lower body dressing. The MDS also indicated Resident 1 used a manual wheelchair, required moderate assistance to walk 10 feet and did not attempt to walk 50 feet due to medical condition or safety concerns. A review of Resident 1's credit card bank statement, for the dates from 1/29/2026 to 2/25/2026 indicated the following: - On 2/21/2026, a $107 charge was made at a beauty enhancement (eyelash extension) provider - On 2/21/2026 a $1.25 charge to a person unknown reason - On 2/21/2026 a $1.25 charge to the same person for an unknown reason - On 2/22/2026 a $577.39 charge for a hotel in Las Vegas, Nevada (NV) - On 2/22/2026 a second charge to the same hotel in Las Vegas, NV in the amount of $400 - On 2/24/2026, $126.13 purchase at a dry cleaners 34 miles away from the facility During an interview on 3/24/2026 at 10:48 AM with Resident 1, Resident 1 stated that LVN 1 was "my nurse for a number of months. We got to know each other. She (LVN 1) brought me 3 sets of clothes and gave them to me. I offered to pay and she said no." Resident 1 stated that LVN 1 went with him to from the facility to go to the bank about four or five times with him (Resident 1) to the bank. Resident 1 stated Resident 1 has a debit card and the credit card. Resident 1 stated two or three weeks ago, he gave LVN 1 his credit card to purchase a new cell phone for him which LVN 1 delivered to Resident 1. Resident 1 stated the facility staff took his bank statements from him and then told him that LVN 1 used his credit card for unauthorized purchases. Resident 1 stated law enforcement came and spoke with him. Resident 1 further stated he did not give LVN 1 his credit card to go to Vegas nor permission to use his credit card. Resident stated all this started (incident with LVN 1) because he is too old to be driving. Resident 1 stated he wished LVN 1 had come to him first and they could have come to some agreement. Resident 1 stated he was upset that someone got into his billfold and took it (credit card). Resident 1 stated that LVN 1 never gave him the cell phone, however, a cell phone came about four or five days after "all this happened (incident with LVN 1 and the credit card). During an interview on 3/24/2026 at 12:48 PM, LVN 2 stated that LVN 1 volunteered to accompany Resident 1 to the bank and that LVN 1 was very insistent on taking Resident 1 to the bank. LVN 2 stated that, "Normally we (facility) have people from activities or CNAs (certified nursing assistants) who act like escorts. I thought it was kind of weird that a charge nurse (LVN 1) would want to with him (Resident 1) to the bank." LVN 2 stated that she knew LVN 1 volunteered to accompany was Resident 1 and never anyone other residents. LVN 2 stated that "the facility always in-service us that we are supposed to say no we never take money or gift cards or anything. As money goes they tell us that especially for residents it can be considered financial abuse even if they say it's a gift - we know that that can change." During a phone interview on 3/24/2026 at 1:30 PM, LVN 1 stated LVN 1 escorted Resident 1 to open a bank account after work one day in January 2026. LVN 1 stated she paid the transportation costs for the trip to the bank. LVN 1 stated that Resident told her that he had to fix his account because he didn't have any money. LVN 1 stated that she would buy him cigarettes and that before the incident (credit card) LVN 1 would help Resident 1 because the resident was depressed and no one was paying attention to the resident. LVN 1 stated she asked if Resident 1 could "have a temporary out on pass so he can fix his problem. No one could escort him so I finished my job and I said I could escort him so he could do what he wanted to do. I even paid for the Uber. We (Resident 1 and LVN 1) went to the bank and opened his account." LVN 1 stated Resident 1 wanted a phone and an organizer to put his stuff/things. LVN 1 stated that she don't have enough money to pay Resident 1 what the resident wanted, however, Resident 1 "insisted on giving me his card so that I can buy his thing ...I couldn't set it up (credit card)." LVN 1 stated, "My mistake I should have gone back him his card I did not realize that I was going to be off for 3 days, then he was looking for it (the credit card). I did not return his card because I was sick. I tried to use his credit card because it was not activated I asked him to try. I used the credit card to reserve a hotel." LVN 1 stated Resident 1 insisted on giving LVN 1 his credit card to buy the resident a cell phone.. LVN 1 stated, "I don't remember telling (Resident 1) that I used the card for the hotel reservation or how much I spent." LVN 1 also stated, "I take responsibility and I paid Resident 1 back $1300 in cash to the administrator (ADMIN)." During an interview on 3/24/2026 at 2:37 PM, Discharge Planner (DCP) stated on 3/14/2024, DCP entered the facility and Resident 1 was on the phone with his banking institution but he was confused, so DCP helped him with the call. DCP stated a bank person/staff member where Resident 1 banks, alerted DCP that Resident 1 had balance on his (Resident 1's) credit card. DCP stated the charges on Resident 1's credit card were suspicious. DCP further stated Resident 1 stated he (Resident 1) gave LVN 1 his credit card and LVN 1 was helping him get things done including going to the bank. DCP further stated after hearing the charges she went immediately to tell the Administrator. During an interview on 3/24/2026 at 3:54 PM, the ADMIN stated on 3/6/2026, Friday, I found out that Resident 1 gave LVN 1 his credit card to purchase a cell phone. The ADMIN further stated she verified with Resident 1 that he had not authorized the purchases. The ADMIN stated she then called LVN 1 and told her (LVN 1) that they (ADMIN and LVN 1) needed to talk. The ADMIN stated LVN 1 then came into the facility, brought $1300 in cash because that's the amount LVN 1 charged Resident 1's card and resigned immediately. The ADMIN stated that Resident 1 aid previously she (LVN 1) was purchasing things for Resident 1 like the cell phone. The ADMIN also stated that after conducting an investigation into the situation (Resident 1 and LVN 1), the ADMN determined that LVN 1 financially abused Resident 1. The ADMIN stated, "these are vulnerable people (residents) under no instance do we accept any gifts from residents." A review of the facility's inservice titled "Resident Abuse Prohibition Training," indicated LVN 1 completed and signed the resident abuse prohibition training on 8/26/2025. The Resident Abuse Prohibition Training indicated that the different ... types of abuse included misappropriation of resident's property/financial/fiduciary (is someone who manages money or property for someone else) are types of abuse. . The Resident Abuse Prohibition Training under the section of "Notice to Employees of Obligation to Report a Crime under the Elder Justice Act," indicated that ..." In an event that an allegation of abuse occurs ... Report the abuse allegation to the supervisor then the supervisor will handle the suspension of the alleged abuser and will report allegation/s to the administrator." A review of the facility's Abuse Policy Acknowledgement Form, signed by LVN 1 on 8/26/2025, indicated that by signing, LVN 1 "acknowledged having received the information listed below, have had sufficient opportunity to ask questions and have all my questions answered regarding our policies on abuse... • Abuse Pre-Test • Policy on Abuse Prevention and Mandated Reporting • Abuse Reporting-Mandated Reporting Requirements ... • Abuse Post-Test • Notice to Employees of Obligation to Report a Crime under the Elder Justice Act" A review of the facility's policy and procedures (P & P) titled, "Abuse Prevention," revised 3/2025, indicated, "The Facility does not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation, and/or mistreatment and develops Facility policies, procedures, training programs, and screening and prevention systems to promote an environment free from abuse, neglect, misappropriation of resident property, exploitation, and mistreatment. The Administrator as abuse prevention coordinator is responsible for the coordination and implementation of the Facility's abuse prevention, screening, and training program policies. The P&P further indicated "Misappropriation of resident property" and "financial abuse" are defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. A review of the facility's P & P titled, "Gifts, Gratuities, and Payments," reviewed 3/2025, indicated Our facility prohibits employees from receiving or giving any gift, gratuity, or payment for services rendered; the making of any promise(s) on behalf of the facility; or engaging in any activity, practice, or act which conflicts with the interest of the facility or its residents. The P&P further indicated: 1. No employee of this facility, or any member of his/her immediate family, may give or accept any cash, gifts, special accommodations, favors, or use of property or facilities to or from anyone with whom this facility does business or is negotiating business on behalf of the facility. 2. The giving or accepting of anything of value by our employees to or from any of our suppliers, residents, family members, visitors, or other employees in any form whatsoever is prohibited. Such conduct may be criminal under certain laws. 3. This policy does not preclude gifts of items of nominal value (not to exceed $50.00 per year). Gifts bearing a supplier logo, which are distributed generally and cost no more than five dollars ($5.00), may be excluded from the fifty dollar ($50.00) annual limitation. The facility failed to protect the rights of Resident 1 to be free from financial abuse according to facility's P&P titled, "Gifts, Gratuities, and Payments," reviewed 3/2025, when LVN 1 over the course of three days, made several purchases including reserving a hotel room for LVN 1 and charged Resident 1's credit card during the month of 2/2026. Resident 1 did not authorize the purchases. As a result, Resident 1 was upset because LVN 1 charged $1213.02 to Resident 1's credit card with the resident's permission. This violation, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of the 37 residents in the facility.