Health inspection·January 16, 2026

California Code, Welfare and Institutions Code - WIC § 15630  (b)(1) A mandated reporter who, in their professional capacity, or within the scope of their employment, has observed or has knowledge of an incident that reasonably appears to be physical abuse, as defined in Section 15610.63, abandonment, abduction, isolation, financial abuse, or neglect, or is told by an elder or dependent adult that they have experienced behavior, including an act or omission, constituting physical abuse, as defined in Section 15610.63, abandonment, abduction, isolation, financial abuse, or neglect, or reasonably suspects that abuse, shall report the known or suspected instance of abuse by telephone or through a confidential internet reporting tool, as authorized by Section 15658, immediately or as soon as practicably possible. If reported by telephone, a written report shall be sent, or an internet report shall be made through the confidential internet reporting tool established in Section 15658, within two working days.  F609   §483.12(b) The facility must develop and implement written policies and procedures that:  §483.12(b)(5) Ensure reporting of crimes occurring in federally funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements.  (A) Each covered individual shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of a crime against any individual who is a patient of, or is receiving care from, the facility.  (B) Each covered individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury.          On 12/8/2025, an unannounced visit was made to the facility by the California Department of Public Health (CDPH) to conduct the Annual Health recertification survey and to investigate a complaint regarding accidents.   The facility failed to report an alleged resident to resident between Resident 1 and Resident 2 to the California Department of Public Health(CDPH) in accordance with the facility’s Policy and Procedure (P&P)titled, Abuse Reporting and Investigation. This failure resulted in the facility underreporting alleged abuse and had the potential for the facility to not report future allegations of abuse reported by residents and facility staff. Findings:     A review of the facility census dated 12/8/25 indicated Resident 1 and Resident 2 were discharged from the facility.  A review of the facility's Policy and Procedures (P&P) titled "Abuse Reporting and Investigation", dated 5/2025, indicated that the facility will report ALL allegations of abuse, unless indicated below, as required by law and regulations to the appropriate agencies within 2 (two) hours. The Facility promptly and thoroughly investigates reports of resident abuse, mistreatment, neglect, exploitation, misappropriation of resident property, or injuries of an unknown source when appropriate. The P&P indicated when the Abuse Prevention Coordinator (APC) receives a report of an incident or suspected incident of resident abuse, mistreatment, neglect, exploitation or injuries of an unknown source, the APC will initiate an investigation immediately. The P&P indicated The APC will immediately, or as soon as practicable, notify by telephone the Ombudsman, or law enforcement, and the APC will send a written SOC 341 report to the Ombudsman or Law Enforcement and CDPH Licensing and Certification within 24 hours of the initial report. A review of Resident 1’s Admission Record (AR),the AR indicated that Resident 1 was a 73-year-old female admitted to the facility on 4/24/2025 with diagnoses including,bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), cognitive communication deficits (difficulty communicating because of injury to the brain that controls the ability to think.) A review of Resident 1’s History and Physical (H&P) dated 4/25/2025,indicated that Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1’s Minimum Data Set (MDS- a resident assessment tool) dated 7/17/2025, indicated Resident 1 was severely cognitively impaired (rarely/never made decisions). The MDS indicated that Resident 1 had verbal behavior symptoms directed toward others. A review of Resident 1’s “Change in Condition Evaluation”(COC) dated 7/13/2025,indicated Resident 1 had “behavioral symptoms” with no further documentation describing Resident 1’s behaviors and indicated a change in skin color or condition. The COC indicated a blank where the provider’s notification should be notified. The COC also indicated a blank where Resident 1’s responsible party should be notified. A review of Resident 1’s Situation, Background, Appearance, and Review (SBAR), dated 7/13/25, indicated Resident 1 had a change in skin color or condition. There was no additional information documented on the SBAR. A review of Resident 1’s Progress Notes dated from 7/1/2025 to 7/18/2025, there was no documented evidence related to any unknown injury. A review of Resident 2’s AR indicated that the facility originally admitted Resident 2 on 11/13/2015 and readmitted on 2/4/2025 with diagnoses including dementia (a progressive state of decline in mental abilities), and anxiety disorder (a group of mental health conditions that cause fear, dread and other symptoms.) A review of Resident 2’s MDS dated11/20/2025, indicated Resident 2 was severely cognitively impaired (rarely/never made decisions). The MDS also indicated that Resident 2 required partial/moderate assistance (Helper does less than half the effort) on rolling left-and-right, sit to lying, and lying-to-sitting on side of bed. A review of Resident 2’s Progress Notes dated from 7/1/2025 to 7/31/2025, there was no documented evidence related to any incident involving Resident 2 and Resident 1. A review of Resident 2’s “Change in Condition Evaluation” from 7/1/2025 to 7/31/2025, there was no documented evidence related to any resident-to-resident altercation between Resident 1 and Resident 2. During an interview on 12/15/2025 at 11:39 AM with the Staff Coordinator (SC) 1, SC 1 stated on 7/13/2025 SC 1 started her shift at 5 AM. SC 1 stated she was in Station 1 when she heard a noise coming from the Resident 1 and 46’s room. SC 1 stated she responded to the noise and saw Resident 1 and 46 looked like they just had an argument, SC 1 stated the incident was reported to LN 7 and LN 7 went to the resident’s room. SC1 stated Resident 1 alleged that Resident 2 hit Resident 1 to the head that had left a mark. SC 1 showed surveyor the photo she held in her phone, stated she kept the photo just to assist staff with their investigation. During a concurrent review of the photo, the photo was taken from the anterior left angle of Resident 1’s face and showed a peach-colored mark, size of approximately one inch in diameter, located on upper left portion of the resident’s forehead. SC 1 further stated that later the ADM came to the facility and informed SC 1, LN 2, and LN 7 that he would take care of the alleged incident between Residents 45 and 46 and told them not to report the incident to anyone. During an interview on 12/15/2025 at 12:59 PM with Licensed Nurse (LN) 2, LN 2 stated that on 7/13/2025 between 5 AM to 6 AM, LN 2 recalled there was an incident which occurred in Resident 1’s room. LN 2 stated that together with LN 7, they heard a commotion coming from Resident 1’s room. LN 2 stated, LN 2 and LN 7 responded to the noise and saw that Resident?45 and Resident 2 “looked upset.” Resident 2 informed LN 2 that Resident 1 hit her first. LN 2 stated Resident 1 and Resident 2 were separated immediately, and Resident 2 was temporarily moved to another room. LN 2 stated that the administrator (ADM) came in early that morning and LN 2 reported this incident to the ADM, who said that he will “take care of everything.” LN 2 stated this incident occurred close to the morning shift change on 7/13/2025. LN 2 stated since ADM said he would “take care of it,” so LN 2 left after her shift was over and did not call police to report the incident according to the facility P&P. LN 2 stated Resident 1 or Resident 2’s responsible parties or physicians were not notified of the resident to resident altercation. LN 2 stated that the ADM did not interview LN 2 further about the incident. During an interview on 12/15/2025 at 1:30 PM with the ADM, the ADM stated he could not find documented evidence of reporting the alleged resident to resident altercation between Resident 1 and 2 on 7/13/2025. The ADM stated he could not remember anything about the incident. The ADM stated he could not explain why this incident was not documented in the resident’s clinical record on 7/13/2025. The ADM stated that any abuse allegation including injury of unknown source was reportable to all appropriate agencies and should have had facility investigation. During a telephone interview on 12/16/2025 at 8:55 AM with LN 7, LN 7 stated he worked on 7/12/2025 during the night shift as a charge nurse. LN 7 stated on 7/13/2025 at around 5 AM to 5:30 AM ,LN 7 responded to a noise coming from Resident 45’s room. LN 7 stated when he arrived in Resident 1’s room, he saw Resident 1 upset and seated at the edge of his bed, while Resident 2 was seated approximately five to ten feet from Resident 1 and appeared agitated. LN 7 stated LN 2 and LN 7 separated Resident 1 and Resident 2 immediately. LN 7 stated Resident 1 could not state what occurred to LN 7, but LN 7 stated Resident 1 had a red mark in between the upper left portion of the forehead. LN 7 stated he had not documented the incident in Resident 1’s medical record and could not recall if Resident 1 and Resident 2’s responsible parties were notified. LN 7 stated a COC was not completed for both residents on 7/13/25 after the incident, and that when the ADM came in the morning of 7/13/25, the ADM stated since he was the abuse coordinator, he would ‘take care of it.” LN 7 stated a follow up interview was not conducted by the ADM after the incident between Resident 1 and Resident 43 on 7/13/25. The facility failed to report an alleged resident to resident between Resident 1 and Resident 2 to the California Department of Public Health (CDPH) in accordance with the facility’s Policy and Procedure (P&P) titled, Abuse Reporting and Investigation. This failure resulted in the facility underreporting alleged abuse and had the potential for the facility to not report future allegations of abuse reported by residents and facility staff.   These violations had a direct or immediate relationship to the health and safety, or security of Resident 1 and Resident 2 and all other residents of the facility.