Other·March 23, 2026

42 CFR §483.90(i)(4) Maintain an effective pest control program so that the facility is free of pests and rodents. 22 CCR §72523 Patient Care Policies and Procedure (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. 22 CCR §72637 General Maintenance. (f) The facility shall be maintained free from vermin and rodents through operation of a pest control program. The pest control program shall be conducted in the main patient buildings, all outbuildings on the property and all grounds On 2/20/2026 the California Department of Public Health (CDPH) received a complaint alleging for several months there were continuous sightings of cockroaches in the breakroom, The cockroaches were observed throughout the breakroom and entering and coming out of the water dispenser. This had been reported multiple times to the nursing supervisors and the facility's Administrator (ADM) but the problem persisted. On 2/20/2026, the CDPH conducted an unannounced visit to the facility to investigate the complaint allegation. During the investigation, the CDPH determined the facility had a cockroaches. The facility failed to: 1. Ensure it was free from cockroaches. 2. Follow its Policy and Procedure (P/P), titled "Pest Control" dated 5/2008, that indicated the facility maintained an ongoing pest control program to ensure the building was free of insects and rodents. These deficient practices resulted in a report of cockroaches in Resident 1's room, and observations of live and dead cockroaches in the facility's staff breakroom. These deficient practices had the potential for a cockroach infestation to occur affecting residents' health and wellbeing. Resident 1, an 82 year old male, was initially admitted to the facility on 5/16/2024 and readmitted on 6/14/2025. Resident 1 had a diagnosis of anoxic brain damage (when the brain is completely deprived of oxygen causing cell death). A review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 12/16/2025 indicated Resident 1's cognition was moderately impaired. Resident 1 was dependent (helper does all the effort) on staff for toilet hygiene, shower/bath, lower body dressing and needed partial/moderate assistance with eating and oral hygiene. During a tour of the facility on 2/20/2026 at 2 p.m., and a concurrent interview, two large dead roaches were observed on the floor behind the facility's water dispenser, and a live cockroach was observed crawling from under the water machine in the nurse's breakroom. Certified Nursing Assistant (CNA) 4, who was present in the breakroom when the roaches were observed, stated there had been an ongoing problem with cockroaches for a while. During an observation on 2/20/2026 at 2:05 p.m., in the staff's breakroom, a cockroach was observed crawling from underneath the refrigerator and Housekeeper (HS) 1, who was present in the breakroom, stepped on the cockroach. HS 1 stated when she sees a cockroach, she steps on it, reports it to her supervisor, who gives her a pesticide (a chemical or biological substance designed to prevent, destroy, repel, or mitigate [make less severe] pest) spray to use on the cockroach. HS 1 stated cockroaches carry germs, and they should not be in the breakroom because they can spread to the resident's room. During an interview on 2/20/2026 at 1:07 p.m., Resident 1 stated three weeks ago (exact date unknown) he saw a couple of big cockroaches crawling across the wall in his room. Resident 1 stated he told the Maintenance Supervisor (MS) who sprayed his room. Resident 1 stated cockroaches were nasty, and he did not want them in his room. During an interview on 2/20/2026 at 2:15 p.m., CNA 1 stated she had seen cockroaches daily while eating lunch in the breakroom and had reported this to the MS. During an interview on 2/20/2026 at 3 p.m., HS 2 stated the nurses told her about the cockroaches in the breakroom, she stated, she reported it the MS and was instructed to clean the breakroom and spray insecticide (a substance used to kill insects). During an interview on 2/20/2026 at 3:30 p.m., the MS stated the nurses reported to him there were cockroaches in the breakroom two weeks ago (exact date unknown) and he sprayed the breakroom with an insecticide until he could call the pest control company (2/13/2026), that services the facility monthly and more frequently if needed. The MS stated he did not see any evidence of cockroaches in residents' rooms but knew there was a problem in the nurses' breakroom. The MS stated when the Pest Control Company came to the facility, their report indicated there was no pest activity found. The MS stated it was important to call the Pest Control Company when there was a report of pests because if there were cockroaches in one area of the facility, they could spread to the kitchen and residents' rooms, and roaches carry germs. During an interview on 2/20/2026 at 4:15 p.m., the ADM stated he was not aware there were cockroaches in the breakroom, but stated it was important to eliminate cockroaches from the facility due to germs they carry that could affect resident's health. A review of the facility's P&P titled "Pest Control" dated 5/2008, the P&P indicated, the facility maintained an ongoing pest control program to ensure the building was free of insects and rodents. The facility failed to ensure: 1. They were free from cockroaches. 2. They followed its P/P titled "Pest Control" dated 5/2008, that indicated the facility maintained an ongoing pest control program to ensure the building was free of insects and rodents. These deficient practices resulted in a report of cockroaches in Resident 1's room, and observations of live and dead cockroaches in the facility's staff breakroom. These deficient practices had the potential for a cockroach infestation to occur affecting residents' health and wellbeing. These violations, jointly, separately or in any combination, had a direct or immediate relationship to the health, safety, or security and welfare of residents in the facility.