Other·April 23, 2026

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 3/18/2026, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint regarding an allegation of resident-to resident sexual abuse (any sexual activity that occurs without consent [permission]). The facility failed to report an allegation of resident-to resident sexual abuse within 24 hours to the State Survey Agency (SSA), the Ombudsman (an advocate who supports residents by resolving issues related to their health, safety and well-being), and Local Law Enforcement (LLE) in accordance with state law for Resident 1 when the following events occurred: 1. On 3/18/2026, at approximately 9:50 a.m., Social Worker (SW) from Agency 1 reported to the facility`s Social Services Director (SSD) that she (SW) had received an email from Resident 1’s Power of Attorney (POA- a legal document that allows someone else to act on your behalf) alleging that Resident 2 had solicited oral sex and followed Resident 1 wherever he (Resident 1) went in the facility. 2. On 3/18/2026, at approximately 10:15 a.m., the SSD then reported the allegation to the facility`s Incident Coordinator (IC). The IC failed to report the allegation of sexual abuse to the Administrator, who is the designated Abuse Coordinator. As a result, Resident 1 was placed at an increased risk for further abuse, potentially leading to additional unreported incidents and a failure to ensure Resident 1’s safety and protection from harm. A review of Resident 1’s Admission Record indicated the facility originally admitted Resident 1, a 39-year-old male, on 3/12/2021, and readmitted on 4/17/2025 with diagnoses including schizoaffective disorder bipolar type (a mental illness that can affect, thoughts, mood, and behavior with mood swings that range from depressive lows to elevated periods of emotional highs), psychoactive substance abuse (?harmful or hazardous consumption of substances—including alcohol, prescription drugs, and illicit drugs—that alter brain function, mood, perception, or consciousness), and tobacco use. A review of Resident 1’s Minimum Data Set (MDS – a resident assessment tool), dated 1/24/2026, indicated Resident 1 had intact cognitive (mental processes that enable people to think, understand, make decisions, and complete tasks) functioning. The MDS further indicated Resident 1 was independent in ambulating 150 feet (ft-unit of measurement). A review of Resident 2’s Admission Record, indicated the facility admitted Resident 2, a 33-year-old male, on 10/14/2025 with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), psychoactive substance abuse, and anxiety disorder (mental health conditions characterized by excessive, persistent, and uncontrollable fear or worry that interferes with daily life). A review of Resident 2’s MDS, dated 1/24/2026, indicated Resident 2 had intact cognitive functioning and was independent in ambulating 150 ft. During an interview on 3/18/2026 at 12:27 p.m., with Resident 1’s POA, the POA stated that on 3/15/2026, at approximately 6:30 p.m., Resident 1 sent a message to the POA asking to urgently call him (Resident 1) back. The POA stated that during the call, Resident 1 reported that he (Resident 1) had been followed by another resident (did not identify the resident) from the facility courtyard into the hallway and phone booth, where the resident (Resident 2) asked him (Resident 1) for oral sex. The POA further stated that he (POA) reported the information to Agency 1. During an interview on 3/19/2026 at 9:13 a.m., with the SSD, the SSD stated that on 3/18/2026, at approximately 9:50 a.m., she (SSD) received a call from Agency 1’s SW. The SSD stated that the SW had received either an email or a phone call from Resident 1’s POA, alleging that another resident in the facility had solicited oral sex from Resident 1 and followed him (Resident 1) wherever he (Resident 1) went in the facility. The SSD stated that she (SW) immediately reported the information to the IC (on 3/18/2026). During an interview on 3/19/2026 at 9:29 a.m., with the IC, the IC stated that the information received from the SW on 3/18/2026 constituted an allegation of abuse and should have been reported to the law enforcement, the ombudsman, and the SSA within two (2) hours. The IC stated that the purpose of reporting an abuse allegation is to ensure a timely investigation. The IC further stated that the failure to report the allegation of sexual abuse had the potential to compromise Resident 1’s sense of safety and increase the risk of recurrence within the facility. During a follow up interview on 3/19/2026 at 10:23 a.m., with the SSD, the SSD stated that the information received from the SW indicated a potential allegation of sexual abuse. The SSD stated that the facility’s process for reporting allegations of abuse is to notify the IC, DON, and Administrator, as well as to report the allegation to the ombudsman, law enforcement and SSA within two (2) hours. The SSD stated it is important to ensure timely reporting so that there is no ongoing threat to Resident 1’s safety and to facilitate a timely and thorough investigation. The SSD stated that failure to report the allegation had the potential for Resident 1 to not feel safe in the facility. During an interview on 3/19/2026 at 11:40 a.m., with the Director of Nursing (DON), the DON stated that on 3/18/2026, in the view of potential exposure of abuse, the facility staff should have notified law enforcement, the ombudsman, and the SSA within two (2) hours of receiving the information. The DON stated the purpose of the reporting process is to protect residents and ensure a timely investigation is conducted. The DON further stated that the facility staff don’t need to confirm that the incident took place prior to reporting an allegation of abuse. The DON stated the facility staff should have initiated an Incident Report to assess Resident 1 and provide therapeutic care/interventions as needed. The DON stated that failure to report the allegation had the potential to allow undiscovered, unreported and uninvestigated abuse to continue within the facility. The DON stated Resident 1 was placed at risk for experiencing negative psychological or mental effects as a result. The DON stated the facility did not follow its abuse policy and protocol. During a concurrent interview and record review on 3/19/2026 at 11:45 a.m., with the DON, the facility-provided policy and procedure (P&P) titled, “Abuse Reporting-Dependent Adults,” last reviewed on 2/2/2026, was reviewed. The (P&P) indicated that “The Director of Nursing (DON), Program Director, or Incident Report Coordinator (IRC) will be responsible for reporting all suspected incidents of dependent adult abuse as soon as is possible by phone to Department of Public Social Services (DPSS) and follow it up with completed SOC 341 (Report of Suspected Dependent Adult/Elder Abuse) …. 3. DON and Administrator will determine reportable incidents. 4. If the reportable event results in serious bodily injury, a telephone report shall be made to the local law enforcement agency immediately and no later than two (2) hours of the observation, knowledge or suspicion of physical abuse (intentional bodily injury). In addition, a written report shall be made to the local Ombudsman, the California department of Public Health, and the local law enforcement agency within two (2) hours of the observation, knowledge, or suspicion of the physical abuse. 5. If the reportable event does not result in serious bodily injury, the Administrator, or his/her designee, will make a telephone report to the local law enforcement agency within twenty-four (24) hours of the observation, knowledge, or suspicion of physical abuse. In addition, a written report shall be made to the local Ombudsman, the California Département of Public Health, and the local law enforcement agency withing twenty-four (24) hours of the observation, knowledge, or suspicion the physical abuse.” The DON stated the facility’s policy did not address the reporting timeframe for allegations of sexual abuse. The DON further stated that the facility’s policy will be reviewed and revised as necessary. A review of the facility-provided P&P titled, “Abuse Definitions,” last reviewed on 2/2/2026, indicated, “It is the policy of this facility to maintain a living environment for its residents that is professional and free from threat and or occurrence of abuse… ‘Sexual abuse’ includes, but is not limited to, sexual harassment (unwelcome, sex-based conduct: verbal, physical, or electronic), inappropriate touching, sexual coercion (the act of using pressure, manipulation, threats, to engage in unwanted sexual activity), sexual contact (the intentional touching of another person’s intimate parts—directly or through clothing), or sexual assault (when someone either touches another person in a sexual manner without consent or makes another person touch them in a sexual manner without consent).” A review of the facility-provided P&P titled, “Accidents and Incidents-Reporting Requirement of Notable Incidents,” last reviewed on 2/2/2026, indicated, “All accidents or incidents involving residents, employees, visitors, vendors, etc. occurring on our premises must be investigated and reported to responsible agencies as required…. The following Incidents must be Reported… 4. Sexual assault (by either staff or resident). 5. Abuse; Abuse allegation” The facility failed to report an allegation of resident-to resident sexual abuse within 24 hours to the SSA, the Ombudsman, and LLE in accordance with state law for Resident 1 when the following events occurred: 1. On 3/18/2026, at approximately 9:50 a.m., SW from Agency 1 reported to the facility`s SSD that she (SW) had received an email from Resident 1’s POA alleging that Resident 2 had solicited oral sex and followed Resident 1 wherever he went in the facility. 2. On 3/18/2026, at approximately 10:15 a.m., the SSD then reported the allegation to the facility`s IC. The IC failed to report the allegation of sexual abuse allegation to the Administrator, who is the designated Abuse Coordinator. As a result, Resident 1 was placed at an increased risk for further abuse, potentially leading to additional unreported incidents and a failure to ensure Resident 1’s safety and protection from harm. The above violation had direct or immediate relationship to the health, safety, or security of Resident 1.