Health inspection·December 24, 2025

42 CFR §483.12 – Freedom from abuse, neglect and exploitation (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (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. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (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. CCR §72523 – Patient Care Policies and Procedures (a)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. HSC 1418.91 - Report of Incidents of Alleged Abuse or Suspected Abuse (b) A failure to comply with the requirements of this section shall be a Class “B” violation. (d) This section shall not change any reporting requirements under Section 15630 of the Welfare and Institutions Code, or as otherwise specified in the Elder Abuse and Dependent Adult Civil Protection Act, Chapter 11 (commencing with Section 15600) of Part 3 of Division 9 of the Welfare and Institutions Code. On 11/12/2025 at 8:15 p.m., the California Department of Public Health (CDPH) conducted an unannounced standard relicensing survey at the facility. While onsite CDPH investigated Resident 4’s reported allegation of abuse. Based on observation, interview, and record review, the facility failed to: 1. Report immediately, or within two hours, to the State Survey Agency, an allegation of physical abuse involving Resident 4 on 11/12/2025, in which an unknown resident allegedly pulled her hair from behind This deficient practice resulted in CDPH’s inability to investigate the allegations of abuse in a timely manner and placed Resident 4 and other residents in the facility at risk for continued physical abuse. A review of Resident 4’s Admission Record, indicated Resident 4, an 87-year-old female, was admitted to the facility on 8/15/2025 with diagnoses of essential hypertension (high blood pressure) and type 2 diabetes. A review of Resident 4’s Minimum Data Set (MDS, a resident assessment tool) dated 10/9/2025, indicated Resident 4 had moderate cognitive impairment. During a concurrent observation and interview on 11/12/2025 at 9:37 a.m., with Resident 4 and licensed vocational nurse (LVN) 2, Resident 4 stated two to three days prior (actual date unknown) she was in the hallway, and someone (unknown person) pulled her (Resident 4) hair from behind. During an interview on 11/13/2025 at 8:47 a.m., Resident 4 stated she could not remember the date of the incident, but she remembered being in her wheelchair in the hallway and someone (unknown) came behind her and pulled her hair. Resident 4 stated no one was around to see the incident and she was unable to turn around to see who pulled her hair. Resident 4 stated she just felt it happen and screamed but there was no one there to help. During an interview on 11/13/2025 at 9:20 a.m., LVN 2 stated the day prior (11/12/2025) Resident 4 mentioned someone pulled her hair a few days ago (unknown date) but she did not know who it was. LVN 2 stated some residents in Resident 4’s unit (unspecified residents) were unfriendly and there had been some instances of resident-to-resident altercations in the past (unspecified dates) so there was a possibility one of the residents pulled Resident 4’s hair from behind. LVN 2 stated hair pulling was a form of physical abuse. LVN 2 stated when Resident 4 reported an allegation of abuse to him on 11/12/2025 at 8:47 a.m. (the day before), he (LVN 2) should have followed the facility abuse protocol and reported Resident 2’s allegation of abuse to the registered nurse (RN) supervisor (unspecified) and if they were not available, he should have told the administrator (ADMIN), but he did not. During an interview on 11/13/2025 at 9:35 a.m., RN 1 stated she was working with LVN 2 the day prior (11/12/2025) and she was not made aware Resident 4 reported her hair being pulled. RN 1 stated Resident 2’s allegation that someone pulled her hair from the back should have been reported and investigated right away. RN 1 stated an incident of alleged abuse (general) did not have to be validated prior to being reported. During an interview on 11/13/2025 at 9:43 a.m., the ADMIN stated Resident 4’s allegation of abuse (made on 11/12/2025 at 8:47 a.m.) should have been reported right away to the on duty Registered Nurse Supervisor or himself so an investigation could have been started, and the proper agencies could be notified. During an interview on 11/13/2025 at 3:12 p.m., the ADMIN stated LVN 2 did not follow the facility’s Abuse P&P. The ADMIN stated it was important that allegations of abuse were reported right away for residents’ safety and the allegations of abuse should be reported to the proper entities within the regulated timeline. During a review of the facility’s P&P titled “Abuse & Mistreatment of Residents” dated 5/3/2023, the P&P indicated any mandated reporter was to report abuse to their supervisor as well as the State Agency. The facility was to notify the State Agency within 2 hours of the knowledge of alleged abuse incidents. The facility failed to: 1. Report immediately, or within two hours, to the State Survey Agency, an allegation of physical abuse involving Resident 4 on 11/12/2025, in which an unknown resident allegedly pulled her hair from behind This deficient practice resulted in CDPH’s inability to investigate the allegations of abuse in a timely manner and placed Resident 4 and other residents in the facility at risk for continued physical abuse. These violations presented a direct or immediate relationship to the health, safety, security, or welfare of the residents.