Health inspection·January 26, 2026

California Code, Welfare and Institutions Code - WIC § 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 or suspected 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.  F609   §483.12(b) The facility must develop and implement written policies and procedures that:  §483.12(b)(5) Ensure reporting of crimes occurring in federally funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements.  (A) Each covered individual shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of a crime against any individual who is a patient of, or is receiving care from, the facility.  (B) Each covered individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury.  On 12/26/2025 at 9:45 AM, an unannounced visit was made to the facility by the California Department of Public Health (CDPH) to conduct a complaint investigation regarding resident-to-resident abuse. The facility failed to report an allegation of abuse for two of three sampled residents (Resident 1 and Resident 2) within 24 hours to the ombudsman, local police department, and to California Department of Public Health (CDPH) in accordance with the facility’s Policy and Procedure titled, “Abuse and Neglect Prohibition Policy.” On 12/21/25 between 5 PM and 6 PM, a commotion was heard by certified nurse assistant (CNA) 1 and when CNA1 arrived at Resident 1 and Resident 2’s room [Room 1], Resident 1 was observed with a slipper in her hand, and Resident 2, reported to CNA 1 that Resident 1 threatened to hit Resident 2 with the slipper. This failure resulted in the facility not reporting alleged abuse and had the potential for the facility to not report future allegations of abuse reported by residents and facility staff. During a review of Resident 1’s Admission Record (AR), the AR indicated the facility initially admitted Resident 1, a 77 year old female on 6/21/2025 and readmitted on 12/7/2025, with diagnoses that included paranoid schizophrenia (a serious brain disorder that distorts a person's thinking, perception of reality, and emotions) and bipolar disorder (a mental health condition causes extreme mood swings).     During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 12/12/2025, the MDS indicated Resident 1 had severely impaired cognition (ability to understand and make decisions) and memory. The MDS also indicated Resident 1required supervision or touching assistance with eating, partial/moderate assistance with oral hygiene, personal hygiene and chair/bed-to-chair transfer, and substantial/maximal assistance with toileting hygiene and shower/bathe self.   A review of Resident 1’s Care Plan for potential to be physically aggressive related to anger, initiated 12/16/25, indicated the goal was that Resident 1 will not harm self or others. The care plan goal indicated to monitor, and document observed behavior and attempted interventions in behavior logs.   During a review of Resident 1’s Situation, Background, Assessment, and Recommendation (SBAR) Communication Form and Progress Note, dated 12/21/2025, the SBAR indicated Resident 1 was agitated and confused. The SBAR indicated Certified Nursing Assistant (CNA) 1 heard arguing coming from Resident 1’s room (Room 1). When CNA 1 arrived at Room 1, Resident 2 stated Resident 1 threatened to hit Resident 2 with Resident 1’s slipper.   During a review of Resident 1’s Progress Note (PN), dated 12/21/2025 at 6:46 PM, the PN indicated CNA 1 heard noise coming from Room 1. The PN indicated Resident 2 stated that Resident 1 threatened to use Resident 1’s slipper to hit Resident 2. The PN indicated the incident was reported to the Director of Nursing (DON) and the Administrator (ADM).         During a review of Resident 1’s Interdisciplinary Team (IDT) Conference, dated 12/22/2025, the IDT Conference indicated Resident 2 stated that Resident 1 was waving a slipper in Resident 2’s face, and stated that Resident 2 was in Resident 1’s bed. Resident 1 stated Resident 2 would hit Resident 1 if Resident 1 did not get out the bed. The IDT indicated a room change was conducted and Resident 1 was moved to Room 2.     During a review of Resident 2’s AR, the AR indicated the facility originally admitted Resident 2, a 72-year-old female on 9/17/2024 and readmitted on 7/9/2025 with diagnoses that included major depressive disorder (a serious mood disorder causing persistent sadness, loss of interest, and significant impairment in daily life) and hypertension (high blood pressure).   During a review of Resident 2's MDS, dated 12/12/2025, the MDS indicated Resident 2 had severely impaired cognition and memory. The MDS also indicated Resident 2 required setup or clean-up assistance with eating, partial/moderate assistance with oral hygiene, substantial/maximal assistance with personal hygiene, and was dependent on chair/bed-to-chair transfer, and with toileting hygiene and shower/bathe self.   During a review of Resident 2’s SBAR, dated 12/21/2025, the SBAR indicated Resident 2 reported that Resident 1 was confused and thought Resident 2 was in her bed and waved a slipper at Resident 2 and told Resident 2 to get off from the bed.     During an interview on 12/26/2025 at 11:13 AM with Resident 2, Resident 2 stated Resident 1 was her room [Room 1] when the incident on 12/21/25 occurred. Resident 2 stated she was lying in her bed and Resident 1 started yelling angerly at Resident 2 and stated that Resident 2 was lying in Resident 1’s bed. Resident 1 told Resident 2 to get out of her bed. Resident 2 stated Resident 1 had a slipper in her hand and threatened to hit Resident 2. Resident 2 stated she yelled “Stop, Stop.” Resident 2 stated the incident was “scary” for her. Resident 2 stated Resident 1 was moved to a different room.     During an interview on 12/26/2025 at 11:24 AM with CNA 1, CNA 1 stated on 12/21/2025 around 5 PM, she was in the hallway across from Room 1 and heard Resident 2 yelling “Stop, stop” and saw Resident 1 walking out from Room 1. CNA 1 stated Resident 2 reported Resident 1 was trying to hit her.    During a telephone interview on 12/26/2025 at 1:10 PM with the Administrator (ADM), the ADM stated she was informed about incident between Resident 1 and Resident 2 on 12/21/2025 but did not report the incident to California Department of Public Health (CDPH), the ombudsman and the police on 12/21/2025.   During a telephone interview on 12/26/2025 at 1:21 PM with the Director of Nursing (DON), the DON stated that on 12/21/2025, Resident 1 threatened to hit Resident 2 with her slipper because Resident 1 thought Resident 2 was on Resident 1’s bed. The DON stated Resident 1 was confused and was trying to protect her property and space. The DON the facility did not determine the incident between Resident 1 and 2 as abuse and did not escalate it to the level for reporting to CDPH, the ombudsman and police department. During a review of the facility’s policy and procedure (P&P) titled, “Abuse and Neglect Prohibition Policy,” dated 6/2022, the P&P indicated upon receiving information concerning a report of suspected or alleged abuse, mistreatment, neglect, or exploitation the Administrator or designee will perform the following: all alleged violations-immediately but not later than 2 hours-if the alleged violation involves abuse or results in serious bodily injury or 24 hours if the alleged violation does not involved abuse and does not result in serious bodily injury. The P&P indicated to report the incident to the local ombudsman or the local law enforcement agency; and that the Licensing and Certification Program District Office is required to receive these reports. During a review of the facility’s P&P titled, Resident to Resident Altercation, updated on December 2026, the P&P indicated if two residents are involved in an altercation staff will report incidents, findings, and corrective measures to appropriate agencies as outlined in the facility’s abuse reporting policy. The facility failed to report an allegation of abuse for involving Resident 1 and Resident 2 within 24 hours to the ombudsman, local police department, and to CDPH in accordance with the facility’s Policy and Procedure titled, “Abuse and Neglect Prohibition Policy.” This failure resulted in the facility not reporting alleged abuse and had the potential for the facility to not report future allegations of abuse reported by residents and facility staff. These violations had a direct or immediate relationship to the health and safety, or security of Resident 1 and Resident 2 and all other residents of the facility.