Health inspection·February 20, 2026

Code of Federal Regulations, Title 42, Section 483.12(c)(1). 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. California Code, Welfare and Institutions Code – WIC, Section 15630(b)(1) 15630(b) (1) A mandated reporter who, in their professional capacity, or within the scope of their employment, has observed or has knowledge of an incident that reasonably appears to be physical abuse, as defined in Section 15610.63, abandonment, abduction, isolation, financial abuse, or neglect, or is told by an elder or dependent adult that they have experienced behavior, including an act or omission, constituting physical abuse, as defined in Section 15610.63, abandonment, abduction, isolation, financial abuse, or neglect, or reasonably suspects that abuse, shall report the known, suspected, or alleged instance of abuse by telephone or through a confidential internet reporting tool, as authorized by Section 15658, immediately or as soon as practicably possible. If reported by telephone, a written report shall be sent, or an internet report shall be made through the confidential internet reporting tool established in Section 15658, within two working days. California Code of Regulations, Title 22, Section 72523 Patient Care Policies. 72523(a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 12/29/2025, the California Department of Public Health (CDPH, the Department) conducted an unannounced visit to the facility to investigate a complaint regarding resident abuse and resident rights. The facility failed to report allegations of abuse for Resident 3, Resident 4, and Resident 9 to the Department within two hours, in accordance with the facility’s policy and procedure (P&P) titled, "Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment," revised April 2025. As a result, these deficient practices violated Residents 3, 4 and 9’s rights, the notification of allegations of abuse to the Department was delayed and placed Resident 3, Resident 4, and Resident 9 at risk of being subjected to abuse while in the facility. a. A review of Resident 3's Admission Record (AR) indicated the facility admitted Resident 3, a 71-year-old male, on 6/2/2025 and readmitted Resident 3 on 7/3/2025, with diagnoses which included acute kidney failure, chronic obstructive pulmonary disease, and urinary tract infection. A review of Resident 3’s Minimum Data Set (MDS), dated 12/4/2025, indicated Resident 3 had no impairment in cognitive skills and was independent with dressing, toileting, and personal hygiene. b. A review of Resident 4's AR indicated the facility admitted Resident 4, an 89-year-old male, on 6/15/2022 and readmitted Resident 4 on 7/28/2025, with diagnoses which included acute kidney failure, type 2 diabetes mellitus, and muscle weakness. A review of Resident 4’s MDS, dated 11/25/2025, indicated Resident 4 had no impairment in cognitive skills and required substantial/maximal from staff for bathing, lower body dressing and toileting hygiene. The MDS indicated Resident 1 required supervision from staff for oral and personal hygiene. c. A review of Resident 9's AR indicated the facility admitted Resident 9, an 80-year-old male, on 12/29/2023 and readmitted Resident 9 on 9/1/2024 with diagnoses which included atrial fibrillation, muscle wasting and atrophy, and hypertensive chronic kidney disease. A review of Resident 9’s MDS, dated 11/25/2025, indicated Resident 9 had no impairment in cognitive skills. The MDS indicated Resident 9 required substantial/maximal assistance from staff for bathing, lower body dressing and toileting hygiene and required supervision from staff for oral and personal hygiene. During an interview on 12/29/2025 at 12:30 PM with Certified Nursing Assistant (CNA) 4, CNA 4 stated CNA 2 used to be the staff person assigned to give residents (in general) showers. CNA 4 stated around one or two months ago, an allegation was made against CNA 2 that CNA 2 was inappropriate toward a resident (unidentified). During an interview on 12/29/2025 at 1:17 PM with CNA 1, CNA 1 stated another CNA (unidentified) told CNA 1 that CNA 2 was overheard talking to Resident 3 about the size of Resident 3’s penis. CNA 1 stated CNA 1 did not immediately report the allegation against CNA 2 to the Director of Nursing (DON) or the Administrator (ADM). CNA 1 also witnessed on another occasion, CNA 2 acting inappropriately toward Resident 4. CNA 1 stated CNA 2 was standing in front of Resident 4 in the hallway. CNA 1 stated CNA 2 grabbed CNA 2’s breasts and asked Resident 4, “They look good, right?” CNA 1 considered CNA 2’s behavior to be sexual harassment toward Resident 4. CNA 1 stated CNA 1 did not report this incident to the DON or the ADM because CNA 2 was known to behave that way in the past. CNA 1 told Licensed Vocational Nurse (LVN) 1 about CNA 2’s inappropriate behavior towards Resident 4 a few days later, on 11/18/2025. CNA 1 stated LVN 1 then reported CNA 2’s inappropriate behavior towards Resident 4 to the ADM. During an interview on 12/29/2025 at 1:55 PM, the ADM stated CNA 1 informed the ADM that CNA 2 had made a “gesture to herself” in front of Resident 4. The ADM stated the ADM investigated the allegation and determined the incident was not abuse. The ADM stated the ADM did not report the allegation to the Department because the ADM had already investigated the allegation and determined there was no abuse. During an interview on 12/29/2025 at 2:27 PM, CNA 2 stated there was an occasion in the past (date unknown) when the ADM called CNA 2 to the ADM’s office and asked CNA 2 if CNA 2 had been inappropriate towards a resident. CNA 2 stated the ADM did not specify who the resident was. During an interview on 12/30/2025 at 10:30 AM with LVN 1, LVN 1 stated sometime in October or November of 2025, CNA 1 informed LVN 1 of CNA 2’s inappropriate behavior toward Resident 4. LVN 1 told CNA 1 to report the allegations to the ADM. LVN 1 stated LVN 1 did not report the allegations of abuse to the Department. LVN 1 reported to the ADM in October 2025, that Resident 9 had reported to LVN 1 that CNA 3 was aggressive toward Resident 9. LVN 1 stated LVN 1 had not reported Resident 9’s allegation against CNA 3 to the Department. During an interview on 12/30/2025 at 11 AM with Resident 9, Resident 9 stated CNA 3 was very rude. Resident 9 stated when Resident 9 reminded CNA 3 to do something, CNA 3 would be angry. Resident 9 stated CNA 3 told Resident 9 to “shut up.” Resident 9 stated CNA 3 would argue with Resident 9. Resident 9 reported CNA 3’s behavior to LVN 1. During an interview on 12/30/2025 at 4:15 PM, the ADM stated the ADM was not aware of Resident 9’s allegations against CNA 3. A review of the facility's P&P titled, "Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment," revised April 2025, indicated, “If there is an allegation or suspicion of abuse, the facility will make a report to the appropriate agencies as designated by State and Federal laws.” The P&P indicated, “1. In response to allegations of abuse, neglect, exploitation, or mistreatment, the Facility will: a. 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 two (2) hours after the allegation is made if the events that cause the allegation involve abuse or results in serious bodily injury • Not later than twenty-four (24) hours if the events that cause the allegation does not involve abuse and does not result in serious bodily injury 2. Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported to: a. The Administrator of the Facility b. The State Survey Agency c. Adult Protective Services (as appropriate)” The facility failed to report allegations of abuse for Resident 3, Resident 4, and Resident 9 to the Department within two hours, in accordance with the facility’s policy and procedure (P&P) titled, "Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment," revised April 2025. As a result, these deficient practices violated Residents 3, 4 and 9’s rights, the notification of allegations of abuse to the Department was delayed and placed Resident 3, Resident 4, and Resident 9 at risk of being subjected to abuse while in the facility. The above violation, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 3. Resident 4, and Resident 9.