Health inspection·October 24, 2025

The following reflects the findings of the California Department of Public Health during the investigation of complaint number 2617204. A Class B Citation was written. REGULATORY VIOLATIONS: California Code of Federal Regulations. 42 CFR §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. 42 CFR §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. 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 9/16/2025, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint allegation regarding sexual abuse (non-consensual sexual contact of any type or sexual harassment) by a Certified Nurse Assistant (CNA) 2. The facility failed to investigate allegations of sexual abuse for Resident 3 and failed to report the allegations of sexual abuse to California Department of Public Health (CDPH), Ombudsman (a representative that helps families and residents in long-term care facilities by investigating and resolving complaints and serving as an advocate), and to the local law enforcement within 2 hours, failed to suspend the individual involved in the abuse allegations. Resident 3 alleged that he was touched inappropriately in the genital area This deficient practice placed Resident 3 and other facility residents at risk for abuse, and delay required onsite inspection by CDPH. A review of Resident 3's admission record indicated Resident 3 was admitted to the facility on 9/3/2025 with a diagnosis including reduced mobility (having difficulty moving around easily or freely, affecting your ability to perform daily tasks like walking, standing), unspecified altered mental status (thinking, awareness, or behavior has changed from their normal state), essential primary hypertension (when the pressure in your blood vessels is too high). A review of Resident 3's Minimum Data Set (MDS- a resident assessment tool) dated 9/10/2025, indicated the resident is cognitively intact (ability to acquire and understand knowledge), does not have change in behavior, dependent on toileting hygiene, (Helper does all of the effort. Residents do none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the residents to complete the activity. Requires substantial/maximal assistance for shower/bath self (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.) During an interview on 9/16/2025 at 10:59 AM with Certified Nursing Assistant (CNA) 1, CNA 1 stated, "I have worked with Resident 3 once or twice, he is dependent on staff to transfer and feeding." Resident 3 is alert and oriented, able to express his needs, and recognizes staff. During an interview on 9/16/2025 at 11:56 AM with the social services director (SS), SS stated, "a day after (Resident 3) was transferred from the facility (9/14/2025), I was contacted by a General Acute Care Hospital (GACH) social worker about abuse allegations against (Resident 3)." SS stated, the facility has not started investigation of the abuse allegations and have not reported to the appropriate agencies. SS stated, abuse allegations should be reported within 2 hours to CDPH, ombudsman, law enforcement, family., and physician. Resident 3 refused to return to the facility. During an interview on 9/16/2025 at 1:40 PM with MDS coordinator, MDS stated, it is known Resident 3 has been aggressive to staff, the care plan and MDS assessment is in progress. Resident 3 did not exhibit signs of abuse. During an interview on 9/16/2025 at 2 PM with the Director of Staffing Development (DSD), the DSD stated any abuse allegations should be reported to the abuse coordinator. The process for abuse allegations is, report the allegations within 2 hours and follow the facility abuse investigation protocol. During an interview on 9/16/2025 at 2:44 PM with the Director of Nursing (DON), the DON stated, "we have a process for abuse allegations. We must report the allegations within 2 hours, suspend involved staff, and update care plans. Report to CDPH, ombudsman, law enforcement, physician and family members, and start investigations." The DON stated, a couple of days ago (9/14/2025) the facility SS informed me, she has received a call from GACH staff. GACH staff has informed the facility SS, department of health services (DHS) will be called for abuse allegations. DON stated, I told staff to document what took place, I did not start investigation. The employee involved in the abuse allegations is not suspended. During an interview on 9/17/2025 at 10:28 AM with the facility Administrator (ADM), the ADM stated staff should have followed the abuse allegation protocol. The process for any abuse allegation is for the facility to initiate investigation by calling CDPH, reporting to ombudsman, isolating the victim, calling law enforcement, education, and suspend if the alleged abuser is staff. The ADM stated that the employee involved in the abuse allegations is suspended as of today 9/17/2025, reporting the abuse allegation to the appropriate agencies and investigation has started. The employee was suspended day after investigation conducted on 9/17/25. During an interview with CNA 2 on 9/17/25 at 10:13 AM, he refused to answer questions, insisted to record conversations and having someone with him during telephone interview. CNA 2 stated he was unable to recall what took place. A review of the facility's Policy and Procedures (P&P) titled "Abuse Investigate/Prevent/Report Alleged Violation" reviewed on January 2025 indicated, "To ensure resident safety, employees accused of participating in the alleged abuse will be suspended until the findings of the investigation have been reviewed by the administrator. Ensures that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made." The facility failed to investigate allegations of sexual abuse, for Resident 3 and failed to report the allegations of sexual abuse to CDPH, Ombudsman, and to the local law enforcement within 2 hours and failed to suspend the individual involved in the abuse allegations. This deficient practice had the potential to place other facility residents at risk for abuse, and delay required onsite inspection by CDPH. These above violations had a direct relationship to the health, safety, and security of Resident 3.