Health inspection·September 10, 2025

F740 §483.40 Behavioral health services. Each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident’s whole emotional and mental well-being, which includes, but is not limited § 72541.Unusual Occurrences. Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department. An incident report shall be retained on file by the facility for one year. The facility shall furnish such other pertinent information related to such occurrences as the local health officer or the Department may require. Every fire or explosion which occurs in or on the premises shall be reported within 24 hours to the local fire authority or in areas not having an organized fire service, to the State Fire Marshal. Note: Authority cited: Sections 208(a) and 1275, Health and Safety Code. Reference: Section 1276, Health and Safety Code. On 7/29/25at 9 AM the Department of Public Health conducted an unannounced visit to the facility to investigate a complaint regarding Resident Abuse. The facility failed to provide behavioral health care services that included an environment and atmosphere that is conducive to mental and psychosocial well-being and reflected the resident’s care plan goals that included behavior modification for sexually inappropriate behaviors, for Resident 1, by allowing Housekeeper 1 to return to work on (7/12/2025) in the same facility area where Resident 1’s room was located, after Housekeeper 1 reported an unwitnessed sexual assault (when someone touches another person in a sexual manner without consent) attempt made by Resident 1 against Housekeeper 1, on 7/12/2025. Housekeeper 1 reported being followed around and threatened by Resident 1 prior to 7/12/2025. The facility failed to report this incident of sexual abuse to California Department of Public Health (CDPH) Licensing and Certification Office. As a result of this failure, Resident 1’s sexually inappropriate behavior was not addressed by the facility. Housekeeper 1 remained working around Resident 1. This could potentially have led to another attempt of sexual or other types of abuse by Resident 1and resulted in the facility underreporting incidents of abuse. A review of Resident 1's Admission Record (AR) indicated the facility originally admitted Resident 1 on 4/26/2021 with diagnoses that included Paranoid Schizophrenia (a mental disorder characterized by delusions of persecution, grandiosity, or jealousy) and major depressive disorder (a mental health condition characterized by persistent feelings of sadness, loss of interest in activities). A review of Resident 1's MDS dated 5/03/2025 indicated Resident 1 had moderately impaired memory and cognition (ability to think). A review of Resident 1’s progress notes dated 7/12/2025 timed at 3:26 PM authored by Program Counselor 1 indicated, “It was reported to this writer from another staff member that (Housekeeper 1) stated to her that this Resident 1 touched her inappropriately in the B building male bathroom. Upon investigation and interviewing Housekeeper 1 with the help of a translator, was able to provide a statement. See attachment. Upon investigation and interviewing both resident (Resident 1) and Housekeeper 1 it was decided to place resident [Resident 1] on 24 [hr] LOS (line of sight). Staff will continue to monitor. Program Director and Charge Nurse were notified.” A review of Resident 1’s progress notes dated 7/12/2025 timed at 1:10 PM authored by Registered Nurse (RN) 1 indicated, “RN supervisor was notified by program lead counselor about Resident 1 sexually assaulting and harassing a staff member earlier this morning. Written statement was taken, 1:1 counseling, line of sight order in place. Notified Director of Nursing at 1:12 PM, Administrator at 1:25 PM, Resident 1’s Primary physician at 3:02 PM, Resident 1’s Psychiatrist at 3:04 PM. Left voicemail for Resident 1’s Responsible party at 3:48 PM.” A review of Resident 1’s “Post event review” dated 7/12/2025 indicated “IDT met to discuss resident’s incident of sexually inappropriate behavior towards staff. Upon assessment, the resident had offered Housekeeper 1 staff to help move the cleaning cart. It was reported that the resident lunged attempting to hug and kiss staff. Due to Resident 1’s diagnosis his behavior is unpredictable and unavoidable. IDT recommendation 1:1 counseling, placed in line of sight (LOS) monitoring for 24 hours behavior modification for sexually inappropriate behaviors. Care plan updated. See individual treatment plan for further information.” The document was signed by the DON on 7/29/2025. A review of Resident 1’s active care plan for Behavior Problem initiated on 8/05/2021 with a revision date of 7/12/2025, indicated “Resident 1 has a behavior problem related to paranoid delusion,” as manifested by paranoid thoughts causing stress or anger,. The care plan goals included Resident 1 having reduced episodes of paranoid delusions, and care plan interventions included to administer medications as ordered, monitor for any adverse reaction and notify psychiatrist and primary physician if any adverse reaction observed, encourage Resident 1 to discuss fears and concerns, encourage Resident 1 to interact with staff and peers, monitor results of medication and notify any abnormality to medical doctor, and refer to Psychiatrist as needed. A review of facility provided handwritten document with facility stamp dated 7/12/2025, the document indicated “At approximately 7:20 AM, I [Housekeeper 1] was cleaning the hallway when Resident 1 approached me and offered to help me move the cleaning cart to which I said no because it wasn’t his job. I then went to the [male] bathroom, and he [Resident 1] followed me again offered to help me clean and when I said no, he lunged at me to hug me trying to kiss me on the mouth. I immediately tried to get him off me, but he continued trying to grope me. I screamed for help, but no one heard me. He [Resident 1] continued forcing me until I managed to get away and his reaction was to hit me on my [buttocks].” The document included Housekeeper 1’s name written and signed. A review of facility provided handwritten document signed by the housekeeping manager dated 7/18/2025 indicated “I, housekeeping manager offered Housekeeper 1 to move up [change work assignments] to the front of the facility due to the incident that took place in the area where Resident 1’s resides on 7/12/2025. Housekeeper 1 said she did not want to move upfront of the facility. I explained to her what can happen, she [Housekeeper 1] still wants to stay in the area where Resident 1 resides.” During an interview on 7/29/2025 with the Administrator (ADM) at 9:30 am, the ADM stated the incident had occurred a few weeks ago, Housekeeper 1 had reported to facility staff [Program Counselor 1] that Resident 1 attempted to kiss her and groped her. The ADM stated the incident had been investigated, Resident 1 was placed on 24-hour monitoring and Housekeeper 1 was removed and reassigned to work at a different area of the facility away from Resident 1.   During an interview on 7/29/2025 at 10 AM, the Housekeeping Manager (HM 1) stated on 7/12/2025 Housekeeper 1 came to him and reported Resident 1 had approached her (Housekeeper 1) and tried to hug her, forcibly kiss her and put his hands down her shirt. HM 1 stated he went to speak to Resident 1’s counselors who informed him [HM 1] they “would take care of it.” HM 1 stated he then returned to his office and reported the incident to his supervisor. HM 1 stated after making a written statement from Housekeeper 1, he asked her if she felt well enough to stay and finish her shift, to which Housekeeper 1 agreed and requested to return to the same area of the facility in which Resident 1 resided. HM 1 stated Housekeeper 1 is still working in the same assigned area as where the incident occurred. During a telephone interview on 7/29/2025 at 10:43 am with Housekeeper 1, Housekeeper 1 stated, on 7/12/2025 while in the facility hallway, she was going in and Resident 1 came up to her and offered to help push the cleaning supply cart. Housekeeper 1 stated she told Resident 1 she does not need help. Resident 1 then took her cart and pushed it towards the male restroom. Housekeeper 1 stated that in front of the restroom Resident 1 stopped and told her he wanted a hug. Housekeeper 1 stated she told Resident 1 no, because that was against the rules of the facility. Housekeeper 1 stated Resident 1 insisted, extended his arms towards her, lunged at her, and put her against the wall. Housekeeper 1 stated Resident 1 touched her in the middle between her legs by her vaginal area and tried kissing her and touched her breast area over her shirt. Housekeeper 1 stated she was screaming and trying to get a staff member’s attention, but no one came. Housekeeper 1 stated she was eventually able to get Resident 1 off her and told Resident 1 she was going to report him. Resident 1 responded that he did not care because they would not do anything to him and walked away.  During an interview on 7/29/2025 at 12:25 PM with Program Counselor (PC) 1, PC 1 stated on 7/12/2025 she was notified that Housekeeper 1 was sexually assaulted by Resident 1 between 10 to 11 AM by facility staff translating for Housekeeper 1. PC 1 stated she was in the Dining Room with the residents during breakfast when Housekeeper 1 reported the alleged incident occurred and did not hear anything. PC 1 stated Housekeeper 1 continues to work in the same area that the incident occurred with Resident 1, but they “try” to keep an eye on Housekeeper 1 when she is working by herself. A review of the updated facility’s policy and procedure (P&P) titled, Care plans, comprehensive person-centered, with a revision date of March 2022, indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident’s physical, psychosocial and functional needs is developed and implemented for each resident. A review of the updated facility’s policy and procedure (P&P) titled, Behavioral assessment, intervention and monitoring, dated of December 2024, indicated 1. The facility will provide, and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. A review of the facility’s P&P for Unusual Occurrence Reporting, revised in December 2007. indicated the facility would report the following events to appropriate agencies for allegations of abuse, and shall be reported via telephone to the appropriate agencies as required by current law and/or regulations within 24 hours of such incidents A review of the facility’s P&P for Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised on April 2021, indicated to identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property and to investigate and report any allegations within timeframes required by federal requirements. The facility failed to provide behavioral health care services that included an environment and atmosphere that is conducive to mental and psychosocial well-being and reflected the resident’s care plan goals that included behavior modification for sexually inappropriate behaviors, for Resident 1, by allowing Housekeeper 1 to return to work on 7/12/2025 in the same facility area where Resident 1’s room was located, after Housekeeper 1 reported an unwitnessed sexual assault attempt made by Resident 1 against Housekeeper 1, on 7/12/2025. Housekeeper 1 reported being followed around and threatened by Resident 1, prior to 7/12/2025, and the facility failed to report this incident between Resident 1 and Housekeeper 1 to CDPH Licensing and Certification Office since this involved an incident of sexual abuse. As a result of this failure, Resident 1’s sexually inappropriate behavior was not addressed by the facility. Housekeeper 1 remained working around Resident 1. This could potentially have led to another attempt of sexual or other types of abuse by Resident 1and resulted in the facility underreporting incidents of abuse. This violation had a direct relationship to the health, safety, and security of Resident 1 and all residents residing in the facility.