Health inspection·February 27, 2026

The following reflects the findings of the California Department of Public Health during the investigation of complaint number 2727877. A Class State B citation was written. Regulatory Violations: California Code of Federal Regulations: §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must- §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; §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 Regulations Title 22: § 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 Regulations Title 22: § 72527 - Patients' Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (10) To be free from mental and physical abuse. (12) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. On 1/27/2026, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint regarding resident abuse. The facility failed to ensure Resident 1 was free from abuse by: 1. Failing to ensure alleged abuse reported by Resident 1 on 1/26/2026 was immediately investigated, and addressed by facility staff in the required time frame of two hours and 2. Failing to notify appropriate authorities in accordance with state and federal requirements. As a result, there was delayed intervention by the facility, placing Resident 1 and other residents at risk for continued abuse by exposing those residents to further potentially abusive interactions with the alleged abuser. During a review of Resident 1's Admission Record, the Admission Record indicated Resident 1 was admitted to the facility on 10/14/2025 with diagnosis of heart failure (the heart muscle isn't pumping blood as well as it should, failing to meet the body's needs for oxygen and nutrients, leading to fluid buildup (swelling) and symptoms like shortness of breath and fatigue) and need for assistance with personal care. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 10/21/2025, indicated Resident 1 had intact cognition (ability to think, remember and reason) for decisions of daily living, and required maximal assistance (Helper does MORE THAN HALF the effort. Helper lifts or holds trunks or limbs and provides more than half the effort) for showering, upper body dressing, roll left and right, sit to lying, sitting on side of bed, partial assistance (Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunks or limbs, but provides less than half the effort) for oral and personal hygiene, and was dependent (Helper does ALL the effort. Residents do none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the residents to complete the activity) on staff for lower body dressing, toileting, and putting on taking off footwear. The MDS indicated Resident 1 required set up assistance (Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) to eat. During an interview on 1/27/2026 at 11:42 AM with Resident 1, Resident 1 stated that about five days ago, Certified Nursing Assistant 1 (CNA1) cleaned her perineal area and touched her inappropriately in her vagina and has not seen him since. Resident 1 stated she reported to the social worker, but they don't do anything about the matter. During an interview on 1/27/2026 at 12:53 PM with the Social Services Worker (SSW), the SSW reported that Resident 1 reported an allegation of abuse directly to her on 1/26/2026 around 6:30 PM. The SSW acknowledged awareness of the facility's abuse prevention and reporting policy and stated she knew the allegation should have been immediately reported to facility administration. However, the SSW failed to report the allegation to the Administrator, Director of Nursing (DON), or other facility leadership. The SSW acknowledged she did not file an SOC 341 form (the official California Department of Social Services document used to report suspected abuse or neglect of elders (65+) or dependent adults (18-64). It is mandatory for reporters-such as caregivers, health practitioners, and staff-to use this form for documenting physical, mental, financial, or neglect-related abuse), did not call the police, nor call the Ombudsman as per facility protocol. During an interview on 1/27/2026 at 1:07 PM with the Administrator, the Administrator stated she had not been informed of Resident 1's report that staff had touched her inappropriately in her vagina. The Administrator stated this was considered a type of abuse if it did occur and should have been reported to her the day it happened. The Administrator stated the SSW has been provided training and in service on reporting abuse, and she knows what to do as a mandated reporter. During an interview on 1/27/2026 at 1:16 PM with the Director of Staff Development (DSD), the DSD stated that on 1/22/2026, the Ombudsman visited the facility and Resident 1 reported to the Ombudsman that she had been touched inappropriately by a staff member. The DSD stated she failed to ask for details about the allegation and assumed Resident 1 was referring to staff giving her back rubs as Resident 1 usually requests. The DSD stated that CNA1 had not been suspended from the facility and an investigation regarding the alleged abuse had not been started. During an interview on 1/27/2026 at 2:36 PM with the Director of Nursing (DON), the DON stated he was not made aware of the allegation at the time it was reported by Resident 1. The DON stated that failure to report the allegation prevented the facility from implementing immediate protective interventions and placed Resident 1 at risk for continued abuse. During a review of the facility's policy and procedures (P&P) titled "Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating" dated 9/2022, the P&P indicated all reports of resident abuse are immediately reported to the administrator, local, state and federal agencies and thoroughly investigated by facility management. "Immediately" is defined as within two hours of an allegation involving abuse. The administrator immediately reports to local state Ombudsman, state licensing/recertification agency, Adult protective services, law enforcement, facility medical doctor, and resident's attending physician. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. The facility failed to ensure Resident 1 was free from abuse by: 1. Failing to ensure alleged abuse reported by Resident 1 on 1/26/2026 was immediately investigated, and addressed by facility staff in the required time frame of two hours and 2. Failing to notify appropriate authorities in accordance with state and federal requirements. As a result, there was delayed intervention by the facility, placing Resident 1 and other residents at risk for continued abuse by exposing those residents to further potentially abusive interactions with the alleged abuser. This violation had a direct or immediate relationship to the health, safety, or security of Resident 1.