Health inspection·October 17, 2025

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. (i) Annually notifying covered individuals, as defined at section 1150B(a)(3) of the Act, of that individual’s obligation to comply with the following reporting requirements. (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 resident 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. §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. §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 §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. H &S § 1418.91 (a)A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class “B” violation. On 10/2/2025, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint regarding an allegation of quality of care and treatment. The facility failed to report Resident 1’s allegation of misappropriation of resident property (deliberate, wrongful or unauthorized use of a resident’s money or belongings without their consent) when on 9/29/2025 at approximately 6:13 p.m., Resident 1 reported to Registered Nurse 1 (RN 1) that Family Member 1 (FM 1) of Resident 1 had taken possession and control of Resident 1’s house and property. The facility did not report this allegation to CDPH until 10/3/2025, four days after Resident 1 reported to RN 1. As a result, Resident 1 was placed at risk for continued financial exploitation (misuse or theft of a resident’s money, property or assets for personal gain) and emotional distress. A review of Resident 1’s Admission Record indicated the facility admitted Resident 1, a 79-year-old male, on 9/29/2025 with diagnoses including seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares and loss of consciousness), bipolar disorder (a mood disorder that causes intense shifts in mood, energy levels and behavior), and major depressive disorder (a mental health condition characterized by persistent feelings of sadness, hopelessness and a loss of interest or pleasure in daily activities). A review of Resident 1’s History and Physical (H&P - a comprehensive assessment of a resident’s medical condition), dated 9/29/2025 indicated Resident 1 did not have the capacity to understand and make decisions.  A review of Resident 1’s Clinical Admission (an assessment of resident’s condition upon admission) form dated 9/29/2025, timed at 6:13 p.m. indicated that Resident 1 was alert and oriented to person, place, and time (the resident is aware of who they are, where they are, and the current date and time), had mild cognitive (relating to the process of acquiring knowledge and understanding through thought, experience, and the sense) impairment and had clear speech, with the ability to make themselves understood. During an interview on 10/2/2025 at 11:24 a.m., with Resident 1, Resident 1 stated that FM 1 arranged for Resident 1’s admission to the facility in order to take possession of his (Resident 1) house and property. Resident 1 further stated that FM 1 had taken control of his (Resident 1) property and was not allowing him (Resident 1) to return to his (Resident 1) home. During an interview on 10/2/2025 at 2:46 p.m., with RN 1, RN 1 stated that on 9/29/2025, at approximately 6:13 p.m., while completing Resident 1’s admission documentation, Resident 1 reported that FM 1 had taken possession of Resident 1’s house, business, and property. RN 1 stated that Resident 1 appeared agitated and requested to speak with Local Law Enforcement (LLE) and facility management to report the allegation. RN 1 stated that Resident 1 also requested paper and wrote down details of his (Resident 1) allegation including his (Resident 1) address and contact information for individuals who could assist. RN 1 stated that she (RN 1) did not fully read the content Resident 1 wrote. RN 1 stated that Resident 1 was consistent in the information he (Resident 1) provided and repeated his (Resident 1) allegations multiple times. RN 1 further stated that she (RN 1) did not report Resident 1’s allegation to the facility Administrator, as she (RN 1) did not believe it was something that needed to be reported. During an interview on 10/2/2025 at 3:06 p.m., with the Administrator, the Administrator stated that she (Administrator) serves as the facility’s Abuse Coordinator. The Administrator stated that any allegation of abuse, including financial abuse should be reported immediately to ensure prompt investigation and to prevent further abuse in the facility. The Administrator stated that facility staff (RN 1) should have immediately reported Resident 1’s allegation to her (Administrator). The Administrator stated the facility staff failed to report Resident 1’s allegation of financial abuse to CDPH in a timely manner, which placed Resident 1 at risk for further abuse. During a concurrent interview and record review on 10/2/2025 at 4:15 p.m., with the Administrator, the facility’s current policy and procedure (P&P) titled, “Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating,” dated 7/2025 was reviewed. The P&P indicated, “If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to the other officials according to the state law … ‘Immediately’ is defined as: within two hours of an allegation involving abuse or result in serious bodily injury.…”  The Administrator stated Resident 1’s allegation was an example of misappropriation of resident property, and the facility staff should have immediately reported the allegation to the Administrator. A review of the facility-provided P&P titled, “Identifying Types of Abuse,” last reviewed on 7/2025, indicated, “As part of the abuse prevention strategy, volunteers, employees and contractors hired by this facility are expected to be able to identify the different types of abuse that may occur against residents…. Abuse towards resident can occur as…c. visitor-to-resident abuse….” The facility failed to report Resident 1’s allegation of misappropriation of resident property when on 9/29/2025 at approximately 6:13 p.m., Resident 1 reported to RN 1 that FM 1 of Resident 1 had taken possession and control of Resident 1’s house and property. The facility did not report this allegation to CDPH until 10/3/2025, four days after Resident 1 reported to RN 1. As a result, Resident 1 was placed at risk for continued financial exploitation and emotional distress. The above violation had direct or immediate relationship to the health, safety, or security of Resident 1.