Health inspection·September 18, 2025

REGULATORY VIOLATIONS: 22 CCR § 72309. Nursing Service Nursing service means a service staffed, organized and equipped to provide skilled nursing care to patients on a continuous basis. 22 CCR § 72329. Nursing Service (a) Nursing service personnel shall be employed and on duty in at least the number and with the qualifications determined by the Department to provide the necessary nursing services for patients admitted for care. The Department may require a facility to provide additional staff as set forth in Section 72501(g). 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. 22 CCR § 72533 – Employee Personnel Records (a) Each facility shall maintain current complete and accurate personnel records for all employees. (b) Records of hours and dates worked by all employees during at least the most recent 12-month period shall be kept on file at the place of employment or at a central location within the State of California. Upon request such records shall be made available at a time and location specified by the Department. 22 CCR § 72501 - Licensee--General Duties. (a) The licensee shall be responsible for compliance with licensing requirements and for the organization, management, operation and control of the licensed facility. The delegation of any authority by a licensee shall not diminish the responsibilities of such licensee. On 8/6/2025, at 06:10 AM, an unannounced visit was conducted by the California Department of Public Health (CDPH) to investigate a complaint on allegations regarding the facility’s failure to provide sufficient nursing staff to always meet the needs of residents, including falsification of staffing hours and records. CDPH determined that the facility failed to maintain accurate and complete personnel records for Certified Nurse Assistants (CNAs) on 8/3/2025 and 8/4/2025. The facility failed to: 1. Input accurate timekeeping records when manually entering work hours into the ADP system (software used by the facility staff to clock in and out of work) for CNA 1, CNA 2, and CNA 3 without CNA 1, 2, and 3’s knowledge on 8/3/2025 and 8/4/2025, despite documentation showing they were absent from the facility on those dates. 2. Input accurate facility staffing information on the CDPH Form 612 (an official form that tracks the hours of direct care provided by CNAs and other direct caregivers, ensuring compliance with the state's minimum staffing requirements) and CDPH Form 530 (Nursing Staffing Assignment and Sign-In Sheet - a required document for California healthcare facilities to log daily assignments, actual working hours, and patient care responsibilities to demonstrate compliance with minimum direct care staffing hours per patient day regulations). This resulted inaccurate facility staffing data being entered into the system, including CNA names and hours that were not supported by facility sign-in sheets, assignment logs, or documented absence reports. 3. Ensure the facility administrator managed the facility staff’s compliance with all applicable laws and regulations, including accurate documentation, proper staffing and provision of the facility’s code of conduct, in accordance with the facility’s policy and procedure titled “Compliance and Ethics Program Components.” These failures to maintain accurate personnel records and the submission of inaccurate data to CDPH can potentially result in the facility’s compliance with the required minimum staffing requirements and poses a risk to resident care, health and safety. A review of CDPH Form 612, titled “Census and Direct Care Service Hours Per Patient Day (DHPPD),” for 8/3/2025, revealed that Section 8—Actual Direct Care Service Hours and DHPPD—was completed with the following data: * Actual total CNA direct care service hours: 160.4 * Average patient census: 66 * Actual CNA DHPPD: 2.43 Furthermore, Section 8 of the CDPH Form 612 indicated this section (Actual Direct Care Service Hours and DHPPD) must be completed at the end of each 24-hour patient day. A review of a facility-provided document titled “Shift 7:00 AM to 3:30 PM,” dated 8/3/2025, revealed that CNA 1 and CNA 2 were not listed on this CNA assignment sheet. The document included a breakdown of resident room assignments for five other CNAs who worked during that shift but did not reflect any resident assignments for CNA 1 or CNA 2. A concurrent review of the facility’s Nursing Staffing Assignment and Sign-in Sheet (CDPH Form 530) for the 7 AM to 3 PM shift on the same date 8/3/2025, showed the following information: * CNA 1’s name was listed on the sign-in sheet dated 8/3/2025; however, the employee signature area was left blank. A handwritten entry of “7.5” was noted in pencil next to the signature line. * CNA 2’s name was also listed, with the signature area similarly left blank on 8/3/2025. A handwritten entry of “7.5” was recorded in pencil next to the signature line. A subsequent review of a facility-provided document titled “Absence Report,” dated 8/3/2025, indicated that CNA 2’s name was handwritten on the form. The report documented that CNA 2, who was scheduled on 8/3/2025 for the 7 AM to 3 PM shift, had reported an absence to a Licensed Vocational Nurse (LVN) at 1:39 AM on the same date, 8/3/2025. Further review of CNA 1’s facility-provided document titled “Punch Detail (Staff time clock in and out record)” report (ADP system) for 8/3/2025, showed the following information that indicated CNA 1 had time entries on 8/3/2025: * In punch: 7:00 AM * Out punch: 11:00 AM * In punch: 11:30 AM * Out punch: 3:00 PM * Total hours recorded: 7.50 A review of CNA 2’s facility-provided document titled “Punch Detail,” report (ADP system) dated 8/3/2025, showed the following information that indicated CNA 2 had time entries on 8/3/2025: * In punch: 7:00 AM * Out punch: 11:00 AM * In punch: 11:30 AM * Out punch: 3:00 PM * Total hours recorded: 7.50 A review of CDPH Form 612, titled “Census and Direct Care Service Hours Per Patient Day (DHPPD),” for 8/4/2025, revealed the following in Section 8 – Actual Direct Care Service Hours and DHPPD: * Actual total CNA direct care service hours: 158.63 * Average patient census: 66 * Actual CNA DHPPD: 2.40 Furthermore, Section 8 of the CDPH Form 612 indicated this section (Actual Direct Care Service Hours and DHPPD) must be completed at the end of each 24-hour patient day. A concurrent review of the facility-provided CDPH Form 530, titled “Nursing Staffing Assignment and Sign-in Sheet,” for the 7 AM to 3 PM shift on the same date of 8/4/2025, showed CNA 3’s name handwritten on the sign-in sheet. However, the signature portion for CNA 3 was illegible. A review of a facility-provided document titled “Shift 7:00 AM to 3:30 PM,” dated 8/4/2025, indicated room assignments for five other CNAs, but CNA 3’s name was not listed, nor was CNA 3 assigned to any resident care responsibilities on that date (8/4/2025). A subsequent review of the facility-provided document titled “Absence Report,” dated 8/4/2025, showed CNA 3’s name handwritten on the form. The report documented that CNA 3, who was scheduled for the 7 AM to 3 PM shift, had reported an absence to a Licensed Vocational Nurse (LVN) at 2:57 AM on the same date (8/4/2025). However, a review of the facility’s “Punch Detail” report (ADP system) for 8/4/2025, showed the following information that indicated CNA 3 had time entries on 8/4/2025: * In punch: 7:00 AM * Out punch: 11:00 AM * In punch: 11:30 AM * Out punch: 3:00 PM * Total hours recorded: 7.50 On 8/6/2025, at approximately 8:10 AM, an interview was conducted with Payroll Employee (PE) 1, who confirmed that she is responsible for completing the facility’s daily Direct Care Service Hours Per Patient Day (DHPPD) using the CDPH Form 612. PE 1 stated that the process involves calculating the actual CNA direct care service hours by referencing the facility’s daily patient census (number of residents residing at the facility), the Nursing Staffing Assignment and Sign-in Sheet (CDPH Form 530), and the Payroll-Generated Hours Report (a report generated based on individual staff punch detail report), which is grouped by specific labor levels (staff work titles). During the same interview, PE 1 stated that she carefully reviews all supporting documentation to ensure the accuracy of the staff reported hours. PE 1 stated that facility staff occasionally forget to sign the Nursing Staffing Assignment and Sign-in Sheets (CDPH Form 530). In such cases, PE 1 stated she cross-references the Punch Detail reports to verify staff time entries and whether a staff had clocked in and out, because some staff would forget to sign in daily. During a concurrent interview and record review on 8/6/2025 at 8:30 AM, PE 1 verified that there were missing staff signatures (CNAs 1, 2, 3) on the facility’s Nursing Staffing Assignment and Sign-in Sheets (CDPH Form 530) for both 8/3/2025 and 8/4/2025. During an interview and concurrent record review of the facility’s Nursing Staffing Assignment and Sign-in Sheets (CDPH Form 530) for 8/3/2025 and 8/4/2025, on 8/7/2025 at 1:30 PM, CNA 2 stated that although she had been scheduled to work on 8/3/2025 and 8/4/2025, she had called off sick on both days. CNA 2 confirmed that her last day working at the facility was 8/1/2025. During the same concurrent review of CNA 2’s “Punch Detail” Report which listed CNA 2’s name and recorded time entries for 8/3/2025, CNA 2 expressed confusion. CNA 2 stated she did not know why the Punch Detail Report documented she had punched in and out to work on 8/3/2025 at 7 AM, 11 AM, 11:30 AM, 3 PM with total hours of 7.50. CNA 2 stated she had never seen the document before and did not understand why it indicated she had worked that day (8/3/2025), as she had called-in sick and was not present at the facility. CNA 2 further stated that no one from the facility had asked for her permission to clock in and out on her behalf, and she was unsure why someone would do so. CNA 2 stated there was only one time-clock machine in the back of the facility that staff use to clock in with their fingerprints. During an interview and concurrent record review of the Nursing Staffing Assignment and Sign-in Sheet for 8/3/2025 on 8/7/2025 at 1:28 PM, CNA 4 stated that she had worked and signed in for the 7 AM to 3 PM shift on 8/3/2025. CNA 4 stated that on that day, she was assigned three additional patients to care for due to CNA 1 and CNA 2 calling off from work, resulting in the facility being short-staffed for CNAs during the shift. During an interview and concurrent record review of the Nursing Staffing Assignment and Sign-in Sheet for 8/4/2025 on 8/7/2025 at 1:40 PM with Treatment Nurse (TN) 1, TN 1 stated she worked on 8/4/2025. TN 1 stated CNA 3 did not come to work on 8/4/2025, as he had called off prior to the shift per the morning report. During an interview and concurrent record review of the Nursing Staffing Assignment and Sign-in Sheet for 8/4/2025 on 8/7/2025 at 1:47 PM, Restorative Nurse Assistant (RNA) 1 stated she had worked on the 7:00 AM to 3:00 PM shift on 8/4/2025. RNA 1 stated that although she was originally scheduled to work in her usual role as an RNA, she was reassigned to work as a CNA for that day due to CNA 3 calling off sick. RNA 1 reported that she was assigned to care for 14 residents on 8/4/2025, during the shift. During a telephone interview on 8/7/2025 at 2 PM, CNA 1 stated that she did not work on 8/3/2025, as she had called off sick. CNA 1 confirmed that she was not physically present at the facility on 8/3/2025. CNA 1 further stated that she was unaware of anyone clocking in and out on her behalf and expressed confusion as to how she would have documented time entries for 8/3/2025, if she was not at work. CNA 1 stated that no one had requested her permission to clock in and out for her on 8/3/2025. On 8/7/2025, at 2:20 PM, another interview and concurrent record review were conducted with PE 1 regarding the “Punch Detail” records for CNA 1, CNA 2, and CNA 3. PE 1 stated that she had manually entered the clock in (punch in) and clock out (punch out) times into the facility’s (ADP) payroll system for CNA 1 and CNA 2 for 8/4/2025, without the staff’s knowledge or consent. PE 1 further stated that she had also manually entered time entries for CNA 3 on the same date, 8/4/2025 again without CNA 3’s knowledge or approval. PE 1 stated that she later deleted the manually entered time records for all three CNAs from the payroll system on 8/7/2025. PE 1 stated that earlier that morning, between approximately 8:00 and 9:00 AM, she had confirmed with the Director of Staff Development (DSD) that CNA 3 did not work on 8/4/2025. However, PE 1 stated that she did not inquire about the reason for the blank signature line appearing next to CNA 3’s name on the CDPH 530 form, if CNA 3 did not report to work on that date, 8/4/2025. During a concurrent interview and record review on 8/7/2025 at 4:44 PM with the DSD, the DSD verified CNA 1 and CNA 2 had not come to work in the facility on 8/3/2025. The DSD also confirmed CNA 3 had not come to work on 8/4/2025. The DSD stated that she became aware earlier prior to this interview that PE 1 had manually entered time records for CNA 1, CNA 2, and CNA 3 into the facility’s payroll system. However, the DSD stated she did not know why PE 1 had done so. During the concurrent review of the Nursing Staffing Assignment and Sign-in Sheets (CDPH Form 530), dated 8/4/2025, which included a signature next to CNA 3’s name, the DSD stated she did not know why an illegible signature was present, as CNA 3 had not worked that day. The DSD further stated that she had not investigated the irregularity or informed the Administrator about it, because she assumed that another staff member may have signed in that area by mistake. During another interview on 8/7/2025 at 4:11 PM with PE, PE 1 disclosed that she had been instructed by the Director of Staff Development (DSD) to access the facility’s payroll system and manually input working hours for three CNAs (CNAs 1, 2, 3). PE 1 stated that the DSD directed her to enter hours for CNA 1 and CNA 2 to reflect that they had worked on 8/3/2025. Additionally, PE 1 reported that she was instructed to input hours for CNA 3 to indicate that CNA 3 had worked on 8/4/2025. According to PE 1, the DSD explained that these entries were necessary because, without them, the facility would not meet the daily staffing requirements mandated by the State. PE 1 stated that the DSD allegedly expressed concerns that failure to meet these requirements would result in the facility being fined. PE 1 further stated that the false entries on the three CNAs payroll system and staffing records were made solely at the direction of the DSD and were not based on actual hours worked by CNAs 1, 2, and 3 on the specified dates in question. During an interview on 8/08/2025 at 4:45 PM with Administrator (ADM), ADM stated she was unaware that PE 1 had been altering employees time records to reflect that they were working when in fact they were not in the facility. ADM stated she was unaware the DSD had access to log into the payroll system. The ADM stated that altering employee timekeeping records is not a facility practice and should never be done by anyone in the facility. A review of the facility’s policy and procedure (P&P), revised 08/2022, the P&P indicated staff numbers, and the skills requirements of direct care staff are determined by the needs of the patients based on each patient’s plan of care, the patients' assessments and the facility assessment. A review of the facility’s P&P titled “Compliance and Ethics Program Components” dated December 2020, indicated the facility is committed to integrity, transparency, and accountability, and to promoting a culture of ethical and lawful practices. The P&P indicated that operational areas at high risk for fraud and abuse are monitored carefully and audi