Health inspection·January 16, 2026

§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(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. §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. § HSC 1418.91 Abuse Reporting (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 11/25/2025, the California Department of Public Health (CDPH) received a Facility Reported Incident (FRI) reporting that a resident (Resident 3) entered another resident's (Resident 2) room, screaming, yelling, swinging at, punching, and throwing things at Resident 2. Resident 3 scratched Resident 2 face. On 12/1/2025, CDPH conducted an unannounced visit to the facility to investigate the FRI. During the investigation, CDPH determined Resident 3, who had a history of schizophrenia (a mental illness that is characterized by disturbances in thought), struck Resident 2 repeatedly on his head with a plastic water pitcher and her fists. Resident 3 also alleged that Resident 2 "shot her and raped her." The facility failed to: 1. Report an allegation of sexual abuse to CDPH when Resident 3 was heard by facility staff accusing Resident 2 of "raping her." 2. Follow the facility's undated Policy and Procedure (P/P) titled "Abuse, Neglect and Exploitation" which indicated when abuse, neglect, or exploitation is suspected, the Licensed Nurse should contact the State Agency to report the alleged abuse. This deficient practice resulted in CDPH being unaware of an allegation of sexual abuse and the inability to investigate the allegation timely. As a result, there was a delay in the investigation by CDPH. This deficient practice had the potential for information to be lost and/or forgotten and placed Resident 3 at risk for continued abuse. Resident 3, a 64-year-old female, was admitted to the facility on 11/17/2025 with a diagnosis of metabolic encephalopathy (brain dysfunction) and schizophrenia. A review of Resident 3's Minimum Data Set ([MDS] a resident assessment tool) dated 9/21/2025 indicated Resident 3's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired and Resident 3 required substantial/maximal assistance (helper does more than half the effort) to complete her ADLs. During an interview on 12/2/2025 at 2:48 p.m., Resident 7 stated he saw Resident 3 enter Resident 2's room, go straight to Resident 2 and said, "you're the one" "you raped me." During a telephone interview on 12/3/2025 at 8:54 a.m., Certified Nursing Assistant (CNA) 1 stated she was taking out the linen and trash barrels near the kitchen area (11/25/2025 date unknown) when she saw someone (Resident 3) rush into Resident 2's room, she then saw Resident 3 throw water from a pitcher onto the floor, then proceeded to hit Resident 2 with the water pitcher. CNA 1 stated Resident 3 was screaming and cursing at Resident 2 saying "he gave me a shot, and he raped me." CNA 1 stated she provided a written report to Registered Nurse (RN 1) but did not include Resident 3's accusation that Resident 2 raped her because she thought RN 1 would report it since she (RN 1) was nearby when Resident 3 made the allegation. During an interview on 12/3/2025 at 9:43 a.m., RN 1 stated she overheard (date and time unknown) CNA 1 talking about Resident 3's allegation that Resident 2 raped her and she (RN 1) reported that allegation to the Director of Nursing (DON). During an interview on 12/3/2025 at 1:45 p.m., the DON stated he was aware of Resident 3's allegation that Resident 2 raped her but forgot to include the allegations of rape when he reported the resident-to-resident incident between Resident 2 and Resident 3 to CDPH. During an interview on 12/3/2025 at 3:04 pm, the Administrator (ADM) stated he was not aware of the rape allegation made by Resident 3, had he known about the allegation, he would have reported it to CDPH. The ADM stated the allegation should have been reported to the CDPH because facility staff were mandated reporters. A review of the facility's undated P/P titled "Abuse, Neglect and Exploitation" indicated when abuse, neglect, or exploitation was suspected, the Licensed Nurse should contact the State Agency to report the alleged abuse. The facility failed to: 1. Report an allegation of sexual abuse to CDPH when Resident 3 was heard by facility staff accusing Resident 2 of "raping her." 2. Follow the facility's undated P/P titled "Abuse, Neglect and Exploitation" which indicated when abuse, neglect, or exploitation is suspected, the Licensed Nurse should contact the State Agency to report the alleged abuse. This deficient practice resulted in CDPH being unaware of an allegation of sexual abuse and the inability to investigate the allegation timely. As a result, there was a delay in the investigation by CDPH. This deficient practice had the potential for information to be lost and/or forgotten and placed Resident 3 at risk for continued abuse. These violations, jointly, separately or in any combination, had a direct or immediate relationship to the health, safety, or security and welfare of Resident 3.