Health inspection·October 6, 2025

Code of Federal Regulations, Title 42, Section § 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. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. California Code of Regulations, Title 22, Section § 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. California Code, Welfare and Institutions Code W&I § 15630 (b) (1) (A) (i)(I)(II) (ii) (I)(II)(III) (iii) (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. (A) If the known, suspected, or alleged abuse occurred in a long-term care facility, except a state mental health hospital or a state developmental center, the following shall occur: (i) If the abuse was allegedly caused by another resident of the facility with dementia diagnosed by a licensed physician and there was no serious bodily injury, the reporter shall submit a written report of the known, suspected, or alleged instance of abuse to both of the following agencies within 24 hours: (I) The long-term care ombudsman. (II) The local law enforcement agency. (ii) In all other instances, immediately or as soon as practically possible, but no longer than two hours, the reporter shall submit a verbal report of the known, suspected, or alleged instance of abuse to the local law enforcement agency, and shall submit a written report to all of the following agencies within 24 hours: (I) The long-term care ombudsman. (II) The local law enforcement agency. (III) The corresponding state licensing agency. (iii) For purposes of this subparagraph, the time limit for reporting begins when the mandated reporter observes, obtains knowledge of, or suspects the abuse or neglect. On 8/14/2025 at 9 AM, the California Department of Public Health (CDPH) conducted and unannounced visit to the facility to investigate an incident regarding resident abuse. As a result of the investigation, the CDPH determined that the facility failed to report an allegation of abuse for Resident 8 to the CDPH, the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and to the local law enforcement, within two hours, in accordance with the facility’s policy and procedure (P&P), titled “Abuse Investigation and Reporting,”  dated 7/2017. This failure violated Resident 8’s rights and resulted in the delay of notification to the Department and had the potential to result in Resident 8 to be subjected to abuse while at the facility A review of Resident 8’s Admission Record (AR) indicated Resident 8 was a 76-year-old female. The AR indicated the facility originally admitted Resident 8 on 7/5/2025, and readmitted the resident on 8/15/2025 with diagnosis that included type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic pulmonary edema (a long-term condition where fluid accumulates in the lungs), and toxic encephalopathy (a brain disorder caused by exposure to poisonous substances, leading to symptoms such as confusion, memory loss, and changes in personality). A review of Resident 8’s “Minimum Data Set (MDS, a resident assessment tool),” dated 7/12/2025, the MDS indicated Resident 8 was mild impaired in cognitive skills (ability to make daily decisions). The MDS indicated Resident 8 required substantial/maximal assistance (helper does more than half the effort to lift or hold trunk or limbs and provides more than half the effort) for toileting hygiene, shower/bathe self, upper and lower body dressing, and putting on/taking off footwear. Resident 8 required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for personal hygiene. A review of Resident 8’s Progress Notes (PN), dated 8/17/2025, the PN indicated the Social Service Director (SSD) interviewed Resident 8, and Resident 8 stated a CNA wearing green scrubs (CNA 2) told Resident 8 to shut up and hit Resident 8 on the mouth during 8/15/2025 night shift (from 8/15/2025 at 11 p.m. to 8/16/2025 at 7 a.m.). During a phone interview on 8/18/2025 at 1:55 PM with CNA 2, CNA 2 stated CNA 2 did not report when Resident 8 told CNA 2 “You are hitting me” during 8/15/2025 night shift when CNA 2 was providing care to Resident 8. CNA 2 stated CNA 2 should report to charge nurse, administrator, local law enforcement immediately when an allegation of abuse was made by residents. During an interview on 8/18/2025 at 3:52 PM with the DON, the DON stated staff should report allegations of abuse to the CDPH, local law enforcement, and ombudsman within two hours. During an interview on 8/19/2025 at 3:35 PM with the Administrator, the Administrator stated, the Administrator, did not receive an allegation of abuse report from CNA 2 during 8/15/2025 night shift (11pm to 7am). A review of the facility’s policy and procedure (P&P) titled, “Abuse Investigation and Reporting,” dated 7/2017, the P&P indicated, “An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or t. Twenty-four (24) hours, if the alleged violation does not involve abuse AND has not resulted in serious bodily injury.” The facility failed to report an allegation of abuse for Resident 8 to the CDPH, the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and to the local law enforcement, within two hours, in accordance with the facility’s policy and procedure (P&P), titled “Abuse Investigation and Reporting,”  dated 7/2017. This failure violated Resident 8’s rights and resulted in the delay of notification to the Department and had the potential to result in Resident 8 to be subjected to abuse while at the facility This violation jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 8.