Health inspection·January 9, 2026

California Code of Regulations, Title 22, Section (a) § 72315. Nursing Service - Patient Care. Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. § 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. Code of Federal Regulations, Title 42 F600 §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; The California Department of Public Health (CDPH) made an unannounced visit to the facility on 11/25/2025 to investigate a complaint of abuse The facility failed to document, monitor and address Resident 1’s behavior changes of screaming toward other residents on 11/12/25. This led to Resident 1 experiencing physical abuse by other residents. As a result, Resident 2 hit Resident 1 on the face on 11/12/2025 and Resident 1 sustained a scratch under her right eye and redness on the right side of the nose. During a review of Resident 1’s Admission Record, the admission record indicated Resident 1 was admitted to the facility on 5/26/2025 with the diagnosis included but not limited to diagnoses of dementia (a progressive state of decline in mental abilities), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), depression (a serious mood disorder characterized by persistent sadness and loss of interest, affecting how a person thinks, feels, and acts) and anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome). During a review of Resident 1’s Minimum Data Set (MDS – a resident assessment tool), dated 9/8/2025, the MDS indicated the resident was severely impaired in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated that the resident was dependent on staff for her activities of daily living. The MDS also indicated Resident 1 did no of the effort to complete the activities of daily living and 2 or more helpers were needed for the resident to complete the activity) with toileting hygiene, shower/bathe self but required substantial/maximal assistance (helper does more than half the effort. Helper lifts or hold trunk and provides more than half the effort) with lower body dressing, putting on/taking off footwear, and oral hygiene. The MDS indicated the resident required partial/moderate assistance with eating, upper body dressing and personal hygiene. During a review of Resident 1’s SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 11/12/2025, the SBAR indicated Resident 1 had a resident-to-resident altercation and had a scratch under the right eye and redness on the right side of the nose. During a review of Resident 1’s Progress Notes, dated 11/12/2025 at 11:30 AM, the Progress Notes indicated Resident 1 stated he was hit by Resident 2 in the face. The progress notes indicated Resident 1 had a scratch under his right eye and discoloration on the right side of his nose. During an interview on 11/25/2025 at 12:48 PM, Treatment Nurse (TN) stated she heard Resident 1 screaming on 11/12/2022 around 10:30AM and when TN went into the resident’s room and checked on Resident 1, the resident had a scratch under his right eye. During an interview on 11/25/2025 at 1:02 PM, Resident 1 stated Resident 2 hit Resident 1 in the face (unable to recall when). During an interview on 11/25/2025 at 1:28PM, Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 1 likes to get into other residents’ personal space. CNA 1 also stated she did not report it, because everyone knows about Resident 1’s behavior. During a review of Resident 2’s Admission Record, the Admission Record indicated the resident was originally admitted to the facility on 2/21/2024 and was readmitted on 1/29/2025 with the following but not limited to diagnoses of muscle weakness and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (muscle weakness on one side of the body that can affect the arm, leg, hand, or face) of the right dominant side. During a review of Resident 2’s MDS, dated 11/13/2025, the MDS indicated the resident is moderately impaired in cognitive skills for daily decision making. The MDS also indicated that the resident required substantial/maximal assistance with shower/bathe self, lower body dressing, and putting on/taking off footwear but required partial/moderate assistance with oral hygiene, toileting hygiene, upper body dressing and personal hygiene. During an interview on 11/25/2025 at 1:20PM, Resident 2 stated, he did hit Resident 1 in the face (unable to recall when). During a review of Resident 3’s Admission Record, the Admission Record indicated the resident was originally admitted on 12/8/2023 and was readmitted on 6/12/2025 with the following but not limited to diagnoses of schizoaffective disorder, depression and anxiety. During a review of Resident 3’s MDS, dated 11/17/2025, the MDS indicated the resident was independent in cognitive skills for daily decision making. The MDS also indicated the resident was dependent on toileting hygiene, shower/bathe self, lower body dressing, and putting on/taking off footwear but required substantial/maximal assistance with oral hygiene, upper body dressing and personal hygiene. During an interview on 11/25/2025 at 2:24 PM, Resident 3 stated, on 11/11/2025, Resident 1 was trying to get Resident 3’s phone (resident unable to recall where in the facility the incident happened) but when Resident 3 did not allow Resident 1, Resident 1 started screaming and staff had to separate both residents. During an interview on 11/26/2025 at 11:22AM, the Director of Nursing (DON) stated if the incident between Resident 1 and Resident 3 had been addressed, then Resident 1 and Resident 2’s incident could have been prevented. The DON also stated the staff who separated Resident 1 and Resident 3 should have reported the incident to the licensed nurse to ensure there were interventions in place to prevent another incident from happening. During the same concurrent interview and record review on 11/26/2025 at 11:22 AM of Resident 1’s Care Plan, dated 11/11/25 to 11/25/2025, the DON stated the facility should have created a care plan for Resident 1’s behavior of screaming toward another resident that happened on 11/11/2025 to prevent further occurrences. During the same concurrent interview and record review on 11/26/2025 at 11:22 AM of Resident 1’s Medical Record, from 11/11/2025 to 11/25/2025, the DON stated the argument incident between Resident 1 and Resident 3 should have been reported and addressed, but, monitoring was not performed, and no interventions were implemented aside from separating the residents. During an interview on 11/26/2025 at 11:57 AM, the DON stated Resident 1’s behavior of screaming to staff and/ or resident on 11/11/2025 was a change of condition (COC - A significant shift in a resident's physical, mental, or functional status that won't resolve on its own without intervention) required a plan of care. During a concurrent interview and record review on 11/26/2025 at 12:10 PM, the facility’s Policy and Procedure (P&P) titled, “Change of Condition,” revised 7/2022, was reviewed. The P&P indicated a sudden change in the resident’s condition manifested by a marked mental behavior will be communicated to the physician immediately for evaluation. The DON stated any mental change is a change of condition and needs to be communicated with the physician promptly (within an hour). The DON also stated the incident between Resident 1 and Resident 3 was not communicated to the physician. During the same concurrent interview and record review on 11/26/2025 at 12:10 PM, the facility’s undated P&P titled, “Abuse Policy,” was reviewed. The P&P indicated the purpose is to prevent abuse by establishing a safe environment, identifying, correcting and intervening in situations in which abuse is more likely to occur, put systems in place for provision of care and services for all residents, assessing and implementing appropriate interventions for residents with behaviors that can lead to conflict or neglect (fail to care properly). The DON stated to identify situations in which abuse is likely to occur such as if the incident between Resident 1 and Resident 3 was addressed, then the incident between Resident 1 and Resident 2 could have been prevented. During the same concurrent interview and record review on 11/26/2025 at 12:10 PM, the facility’s P&P titled “Behavior Assessment and Monitoring,” revised 1/2025, was reviewed. the P&P indicated problematic behavior will be identified and managed appropriately. The P&P also indicated new onset or worsening behavioral symptoms will be identified and will be documented regardless of degree of risk to resident or others. The DON stated Resident 1’s behavior should have been identified and managed after the screaming incident with Resident 3 that happened on 11/11/2025. The DON also stated it would prevent the incident with Resident 2. The facility failed to document, monitor and address Resident 1’s behavior change of screaming toward other residents on 11/12/25. This led to Resident 1 not free from physical abuse (any intentional act causing injury or trauma to another person through bodily contact), from other residents. As a result, Resident 2 hit Resident 1 on the face on 11/12/2025 and Resident 1 sustained a scratch under the resident’s right eye and redness on the right side of the nose. This violation had a direct or immediate relationship with the health, safety, or security of Resident 1 and other residents in the facility.