Health inspection·March 19, 2026

42 CFR §483.12(c) Reporting of Alleged Violations (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. (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 Code 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. (c) For purposes of this section, "abuse" shall mean any of the conduct described in subdivisions (a) and (b) of Section 15610.07 of the Welfare and Institutions Code. (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 2/5/2026 the California Department of Public Health (CDPH) received a facility reported incident (FRI) indicating Certified Nurse Assistant (CNA) 2, made a sexually inappropriate gesture while providing Resident 2 with care. On 2/5/2026, the CDPH conducted an unannounced visit at the facility to investigate the complaint. The facility failed to: 1) Report a sexual abuse (a non-consensual contact of any type with a resident, including sexual harassment) allegation to CDPH the Ombudsman, and the law enforcement agency when Resident 2 reported to the Director of Staff Development (DSD) (unknown date). As a result, there was the potential for continued abuse by CNA 2 to Resident 2 and other residents in the facility. Resident 2 a 57-year-old male originally admitted to the facility on 4/28/2025 and readmitted on 9/1/2025. Resident 2 had diagnoses including amyotrophic lateral sclerosis (ALS- a fatal neurological disordered characterized by progressive degeneration of nerve cells in the spinal cord and brain) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 2's Minimum Data Set (MDS- a resident assessment tool) dated 11/7/2025, indicated Resident 2's cognition (ability to think, understand, learn, and remember) was intact. The MDS indicated Resident 2 was dependent (helper does all of the effort on activities of daily living (ADLs- activities such as bathing, dressing, and toileting a person performs daily). During an interview on 2/5/2026 at 10:43 a.m., Resident 2 stated approximately a weeks ago (date unknown), CNA 2, made a thrusting gesture with his pelvic area (part of the body between the legs) which was offensive to him. Resident 2 stated he felt CNA 2 was making fun of his sexual orientation and this made him feel angry. Resident 2 stated he reported the incident to the DSD. During an interview on 02/05/2026 at 11:00 a.m. with the DSD, the DSD stated Resident 2 had informed her about CNA 2's inappropriate gesture, but she did not report it. The DSD explained that Resident 2 felt the gesture was mocking his lifestyle because he was gay (attracted to the same gender). The DSD stated, as a mandated reporter, she should have reported the allegation to ensure the resident's safety and to initiate a proper investigation. A review of the facility's policy and procedure (P&P) titled, "Abuse Prevention and Prohibition Program," dated 7/9/2024, indicated, "The facility will report allegations of abuse immediately, but no later than 2 hours after forming a suspicion- if the alleged violation involves abuse to the state survey agency, law enforcement, and the Ombudsman." The facility failed to report a sexual abuse allegation to CDPH when Resident 2 reported to the DSD, that CNA 2, made a sexually inappropriate gesture while providing Resident 2 with personal care As a result, there was the potential for continued abuse by CNA 2 to Resident 2 and other residents in the facility. These violations presented a direct or immediate relationship to the health, safety, security, or welfare of Resident 2.