Health inspection·March 5, 2026

§483.12(c)(1) Abuse Policies and Procedures (reporting) 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. §72523(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 (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 1/20/2026, the California Department of Public Health (CDPH) received a complaint alleging a resident's (Resident 1) wallet and all his money was stolen by someone taking care of him at the facility. On 1/22/2026 (after CDPH entered the facility to investigate the allegation), the CDPH received a Facility Reported Incident (FRI) indicating Resident 1's credit card was charged $800.00 but Resident 1's bank reimbursed him. On 1/21/2026, the CDPH conducted an unannounced visit to investigate the complaint allegation and FRI. Upon investigation, the CDPH determined the facility was aware Resident 1's wallet was missing from the facility while Resident 1 was admitted to a General Acute Care Hospital (GACH) from 11/19/2025 to 11/22/2025, and an unauthorized amount of $800.00 was charged on his credit card. The facility failed to: 1. Notify the CDPH when the facility found out Resident 1's wallet was missing and a debit of $800.00 was charged on his credit card without his permission. 2. Follow its Policy and Procedure (P/P), titled, "Investigating Incidents of Theft and/or Misappropriation of Resident Property" dated 4/2017, that indicated should an alleged or suspected case of staff misappropriation of resident property be reported, the facility's Administrator, or his/her designee, will notify the appropriate regulatory agencies. These failures resulted in a delay in the investigation by the CDPH and placed Resident 1 and other residents at risk for further abuse. Resident 1, a 76-year-old male, was initially admitted to the facility on 9/5/2017 and readmitted on 1/14/2026. Resident 1's diagnoses included metabolic encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition such as viral infection or toxins in the blood), pneumonia (an infection/inflammation in the lungs), acute chronic respiratory failure ( a condition in which the lungs have a hard time loading blood with oxygen or removing carbon dioxide [a colorless, odorless waste gas produced by cellular metabolism that the body transports via blood and exhales through the lungs]), with hypoxia (diminished availability of oxygen to the body tissues), and diabetes mellitus ([DM]a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 11/26/2025, indicated Resident 1's cognition (the ability to think and reason) was intact. The MDS indicated Resident 1 required partial assistance with oral hygiene, substantial/maximal assistance with upper body dressing, supervision or touching assistance with eating, he was dependent with toileting hygiene, lower body dressing and putting on/taking off footwear. A review of Resident 1's Inventory of Personal Effects, dated 11/19/2025, indicated Resident 1 had one billfold/wallet, two credit cards, and four check booklets. A review of Resident 1's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 11/19/2025, indicated Resident 1 was transferred to the emergency department for drowsiness and refusal to eat breakfast. A review of Resident 1's Physician Order, dated 11/22/2025, indicated to readmit Resident 1 to the facility. A review of the facility's Theft and Loss Log, dated 11/2025, indicated on 11/22/2025 (the day Resident 1 was readmitted to the facility), Resident 1 reported his wallet was missing. The Theft and Loss Log indicated on 11/27/2025 the wallet was replaced. A review of Resident 1's Theft/Loss Report, dated 11/27/2025, indicated Resident 1 reported his brown leather billfold/wallet was missing on 11/22/2025 at 2:30 p.m. The Theft/Loss Report indicated the area on the form designated to estimate the value of the lost items and the area designated to indicate if the lost item was listed on the resident's inventory form were left blank. During an interview on 1/21/2026 at 10 a.m., Resident 1 stated he was transferred to the GACH (11/19/2025) and was too sick to remember to take his wallet with him. Resident 1 stated he always left his wallet in the same spot, in the drawer next to his bed, and while he was still in the GACH he asked Family Member (FM) 2 to look for his wallet but FM 2 could not find the wallet in its usual spot, which made him realize the wallet had been stolen. Resident 1 stated someone charged $800.00 to his credit card, but the bank caught it and reimbursed the money back to his account. Resident 1 stated he informed Social Services Staff ( SSS) 1 of the theft of his wallet and the unauthorized $800.00 withdrawal (11/22/2025). Resident 1 stated the facility replaced his wallet but not what was in the wallet. Resident 1 stated FM 1 called (date unknown) SSS 2 to report that his (Resident 1) wallet which contained his credit card, his Medicare card, Medi-Cal card, social security card, family pictures was stolen and an unauthorized charge of $800.00 was withdrawn from his account. During an interview on 1/21/2026 at 11:18 a.m., The Social Services Director (SSD) stated when Resident 1 returned from the GACH (11/22/2025) he reported to SSS 1 (exact date unknown) that someone had taken $800.00 from his bank account, but the bank reimbursed the money to Resident 1. The SSD stated the theft of Resident 1's wallet and the missing money should have been reported to the police since the amount of money that was missing was greater than $100. The SSD stated due to Resident 1's cognitive state he the (SSD) was not sure if Resident 1 could report what happened accurately. During an interview on 1/21/2026 at 11:40 a.m., SSS 1 stated when Resident 1 returned from the GACH (11/22/2025), he reported (exact date unknown) to him that $800.00 was missing from his bank account. SSS 1 stated Resident 1 reported his bank was going to return the money to him, so he (SSS 1) did not think to report the missing money to the CDPH because the matter had been resolved by the bank. During an interview on 1/21/2026 at 2:17 p.m., the Administrator (ADM) stated he was not aware that Resident 1 reported to SSS 1 that $800.00 was missing from his (Resident 1) bank account. The ADM stated if Resident 1 reported $800.00 was taken from his bank account, following the report that his wallet was lost, the missing money should have been reported to the CDPH per regulations. A review of facility's P/P titled "Investigating Incidents of Theft and/or Misappropriation of Resident Property" dated 4/2017, indicated should an alleged or suspected case of staff misappropriation of resident property be reported, the facility's Administrator, or his/her designee, will notify the following agencies within 24-hours of such incident, as appropriate: a. State Licensing and Certification Agency b. Ombudsman c. Resident Representative d. Adult Protective Services e. Law Enforcement Officials The P/P indicated the results of the investigation will be reported to the administrator within five (5) working days of the reported incident, and the administrator or his/her designee will notify the resident and/or the resident's representative of the results of their investigation and the corrective action taken within five (5) working days of the completion of the investigation. The P&P indicated the administrator will report the investigation to the local police department, the ombudsman, and to the state survey and certification agency within five (5) working days of the incident. A review of facility's P/P titled "Identify Exploitation, Theft and Misappropriation of Resident Property, dated 4/2021, indicated staff and providers were expected to report suspected exploitation, theft or misappropriation of resident property. The facility failed to: 1. Notify the CDPH when the facility found out Resident 1's wallet was missing and a debit of $800.00 was charged on his credit card without his permission. 2. Follow its P/P, titled, "Investigating Incidents of Theft and/or Misappropriation of Resident Property" dated 4/2017, that indicated should an alleged or suspected case of staff misappropriation of resident property be reported, the facility's Administrator, or his/her designee, will notify the appropriate regulatory agencies. These failures resulted in a delay in the investigation by the CDPH and placed Resident 1 and other residents at risk for further abuse. These violations, jointly, separately or in any combination, had direct or immediate relationship to the health, safety, or security and welfare of Resident 1.