Health inspection·January 14, 2026

§483.12(c) (1) (4) Freedom from Abuse, Neglect, and Exploitation §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. Title 22 California Code of Regulations: § 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. 22 CCR § 72521 Administrative Policies and Procedures. (a) Written administrative, management and personnel policies shall be established and implemented to govern the administration and management of the facility. On 12/15/2025 the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct a recertification survey. The facility failed to report an allegation (claim that someone did something wrong) of misappropriation (taking or using someone else's money or belongings without their permission) of resident property immediately, but not later than 2 hours after the allegation was made to the California Department of Public Health (CDPH) for Resident 63 on 5/16/2025. As per the facility's policy and procedures (P&P) titled "Abuse, Neglect, Exploitation (treating someone unfairly or taking improper advantage of them for personal gain, using a resident's vulnerability, or situation for one's own benefit) or Misappropriation - Reporting and Investigating," dated 1/2025. This failure delayed an onsite inspection by the California Department of Public Health to ensure Resident 63's allegation was investigated. This failure also had the potential to place Resident 63 at further risk of abuse. During a review of Resident 63's Admission Record, the Admission Record indicated the facility originally admitted the 75 year old male on 1/13/2021 and readmitted on 12/11/2025 with diagnoses that included type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), acute respiratory failure with hypoxia (when the body's tissues and cells don't get enough oxygen to function properly), ischemic cardiomyopathy (the heart muscle gets weak and enlarged because the heart is not getting enough oxygen-rich blood), morbid obesity (having a severe level of excess body fat), and unspecified glaucoma (diseases involving eye pressure increases that lead to permanent vision loss and blindness). During a review of Resident 63's Progress Notes dated 5/16/2025 at 2:09 PM, the Progress Notes indicated Resident 63 was claiming $2k was missing. The notes indicated the resident had asked an unidentified staff to place the money in his "second drawer". The notes indicated the unknown staff told the resident the facility would follow up with the police. During a review of Resident 63's Minimum Data Set (MDS - a standardized resident assessment tool, dated 10/7/2025, the MDS indicated Resident 63 had the ability to understand others and had the ability to make himself understood. During an interview on 12/15/2025 at 10:26 AM, with Resident 63, Resident 63 stated he had lived at the facility for approximately 2 years. Resident 63 stated he reported to the Administrator (ADM) and Social Services Director (SSD) that approximately $2000 was stolen from his room approximately 6 months prior to the date of interview. Resident 63 stated he could not remember the exact date or time. Resident 63 stated the facility reported the alleged stolen $2000 to the police. During an interview on 12/16/2025 at 8:14 AM with the SSD, the SSD stated he (SSD) was familiar with Resident 63's allegation regarding the stolen money. The SSD stated Resident 63 had fluctuating (changing) dollar amounts regarding how much money was stolen. The SSD stated at times Resident 63 reported missing $300 and at other times $3000. The SSD stated he (SSD) reported the allegation of stolen money to local law enforcement only, but could not say the exact date and time, only that it was around May 2025. The SSD stated he (SSD) was a mandated reporter (someone legally required to report suspected physical or financial abuse or neglect). The SSD stated he (SSD) had to check his (SSD) notes to see if the SSD notified the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) or CDPH of the allegation of stolen money. During a follow up interview on 12/16/2025 at 9:07 AM with the SSD, the SSD stated Resident 63's allegation of stolen money on 5/16/2025 was not reported to the Ombudsman or CDPH. The SSD stated that he (SSD) notified local law enforcement and received a police report number. The SSD stated he (SSD) should have reported the allegation to CDPH. The SSD stated he (SSD) was not well versed in the facility's abuse and misappropriation of property policies. During a concurrent interview and record review on 12/16/2025 at 9:52 AM with the Director of Nursing (DON), DSD, and SSD, the facility's P&P titled "Theft and Loss Program" dated 1/2025 and the facility's P&P titled "Abuse, Neglect, Exploitation (treating someone unfairly or taking improper advantage of them for personal gain, using a resident's vulnerability, or situation for one's own benefit) or Misappropriation - Reporting and Investigating," dated 1/2025 were reviewed. The SSD stated he (SSD) only referred to the facility's "Theft and Loss Program" policy which indicated "the facility will report to local law enforcement agency within 36 hours when the Administrator has reason to believe resident's property with a then current value of $100.00 (one hundred dollar) or more has been stolen. Facility will keep logs that contain pertinent information for 12 months" when Resident 63 made the allegation on 5/16/2025 regarding $2000 being stolen. The DSD and DON stated facility staff should have referred to the policy titled "Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating" dated 1/2025, which indicated "all reports of resident abuse (including injuries of unknown origin), neglect, exploitation or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulation) and thoroughly investigated by facility management. Findings of all investigations are documented and reported" when Resident 63 made the allegation regarding $2000 being stolen. During a telephone interview on 12/16/2025 at 10:20 AM with the Ombudsman (OMB), the OMB stated the OMB did not receive any notification from the facility regarding any misappropriation of property in May 2025 for Resident 63. During a concurrent interview and record review on 12/16/2025 at 11:40 AM with the ADM, the ADM reviewed the facility's P&Ps titled "Theft and Loss Program" and Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating," dated 1/2025. The ADM stated Resident 63's allegation on 5/16/2025 of $2,000 being stolen would have only been reported to CDPH and the Ombudsman when the ADM's investigation was completed. The ADM stated that she (ADM) did not report the allegation Resident 63 made on 5/16/2025 because the ADM was not aware of the facility's policy and procedures titled "Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating". The ADM stated the facility should have referred to the "Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating" policy and reported Resident 63's allegations to CDPH and the Ombudsman. During an interview on 12/16/2025 at 11:57 AM with the DSD and DON, the DSD and DON stated the facility should have reported Resident 63's allegation of misappropriation of property on 5/16/2025 to protect Resident 63. The DON and DSD stated the facility had to report to CDPH and the Ombudsman any abuse or misappropriation of property allegations made by any of the facility's residents. During a review of the facility's P&P titled "Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating" dated 1/2025, the policy indicated "all reports of resident abuse (including injuries of unknown origin), neglect, exploitation or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulation) and thoroughly investigated by facility management. Findings of all investigations are documented and reported." During a review of the facility's P&P titled "Theft and Loss Program" dated 1/2025, the policy indicated "the facility will report to local law enforcement agency within 36 hours when the Administrator has reason to believe resident's property with a then current value of $100.00 (one hundred dollar) or more has been stolen. Facility will keep logs that contain pertinent information for 12 months." The facility failed to report an of misappropriation of resident property immediately, but not later than 2 hours after the allegation was made to the CDPH for Resident 63 on 5/16/2025. As per the facility's P&P titled "Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating," dated 1/2025. This failure delayed an onsite inspection by the California Department of Public Health to ensure Resident 63's allegation was investigated. This failure also had the potential to place Resident 63 at further risk of abuse. The above violation had a direct relationship to the health, safety, and security of Resident 63.