Health inspection·February 6, 2026

F656 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. § 72311. Nursing Service--General. (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time-limited. (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 22 CCR § 72315. Nursing Service-Patient Care. (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. 22 CCR § 72527 Patient’s 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: (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 12/19/2025 at 9:30 AM, the California Department of Public Health (CDPH) conducted an unannounced visit to investigate a facility reported incident regarding inappropriate sexual behavior between Resident 1 and 2. The facility failed to create and implement a resident-centered care plan for Resident 2, resulting in its failure to prevent sexual abuse (non-consensual sexual contact of any type with a resident) for Resident 1 and 2 on 12 /18/2025 in the facility’s hallway. On 12/18/2025, Orientee of Dietary (OD) and Certified Nursing Assistant (CNA 1) witnessed Resident 1 pulled down his (Resident 1) pants and pulled out his (Resident 1) penis. Resident 2 then performed oral sex (on Resident 1. This failure resulted in exposure of Resident 1 and 2 to sexual abuse in violation of the above cited standards. A review of Resident 1's Admission Record, the Admission Record indicated Resident 1 is a 61-year-old male who was initially admitted to the facility on 2/21/2024. Resident 1’s diagnoses included cocaine dependence (addictive disorder characterized by compulsive and uncontrollable drug seeking, continued drug use despite negative consequences.), unsteadiness of the feet, and muscle weakness. The admission records also indicated Resident 1 was self- responsible (able to make decisions for himself). A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 11/13/2025, the MDS indicated Resident 1’s cognitive skills (processes of thinking and reasoning) for daily decision making were moderately impaired. The MDS indicated Resident 1 needs partial moderate assistance on (the helper does less than half the effort) on roll left and right (the ability to roll from lying on back to left and right side and return to lying back on the bed) and the resident needed partial moderate assistance when walking 10 feet (ft.-unit of measurement) once standing, in a room, corridor or similar space. A review of Resident 1’s Situation, Background, Assessment and Recommendation (SBAR, tool used by health care professionals when communicating about critical changes in a resident’s status), dated 12/18/2025 at 2:25 PM, indicated there was a situation of inappropriate sexual activity by the hallway. A review of Resident 1’s nurses progress notes dated 12/18/2025 at 2:40 PM indicated on 12/18/2025 at 2:25 PM, the Director of Dietary (DD) and OD came to the nurses station and reported an incident to the charge nurse in which the OD was outside standing in the patio area, facing towards the facility entrance building and witnessed (from the glass window) Resident 1 pull down his pants and pull out his penis. The progress notes also indicated OD witnessed Resident 2 perform oral sex to Resident 1. During a review of Resident 2's Admission Record, the Admission Record indicated Resident 2 is an 81-year-old female was initially admitted to the facility on 1/5/2017. Resident 2’s diagnoses included schizoaffective disorder (a mental illness that causes loss of contact with reality), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and hypertension (high blood pressure). The Admission Record indicated Resident 2 was not self-responsible and the responsible party is Resident Representative 1. A review of Resident 2's MDS dated 11/1/2025, the MDS indicated Resident 2’s cognitive skills for daily decision making is cognitively intact. The MDS indicated Resident 2 needs substantial maximal assistance (helper does more than half the effort) on roll left and right, walk 10 ft., once standing at least 10 ft in a room, corridor or similar space. A review of Resident 2’s SBAR dated 12/16/2025 at 10:52 AM, the SBAR indicated Resident 2 had an episode of throwing feces in the hallway, attempting to touch or kiss the staff and residents’ hands, and wandering (the act of a resident with cognitive impairment moving around in the facility without appreciation for personal safety, potentially entering into harm's way) into other residents’ rooms. A review of Resident 2’s care plan initiated on 12/16/2025 indicated Resident 2 has exhibited socially inappropriate / disruptive behavioral symptoms as evidenced by: touching and kissing hands of staff and residents. The care plan included an intervention to observe socially inappropriate, disruptive behaviors when Resident 2 was around others. A review of Resident 2’s nurses progress notes dated 12/18/2025 at 4:13 PM, the nurses progress notes indicated at approximately 2:15 PM, CNA 1 saw Resident 2 with Resident 1 having oral sex in the hallway. CNA 1 was coming from outside and saw Resident 1 and 2 having oral sex then CNA 1 knock on the glass door and Resident 1 immediately pulled his pants up and walked away. A record review of facility’s incident written statement from date 12/18/2025 indicated on 12/18/2025 at 2:15 PM OD witnessed Resident 1 pulled down his pants and pulled out his penis, then Resident 2 performed oral sex to Resident 1 at the hallway. A record review of facility’s “Resident Interview Form” dated 12/18/2025 at 3:33 PM indicated Resident 1 was interviewed by the Director of Nursing (DON) and Activity Director (AD). The Resident interview form indicated Resident 1 immediately stood up when asked about what happened and stated, “I do not want to talk about it, I do not want to say anything at all I am not talking to you both.” The Record Review Form also indicated at 4:05 PM, Resident 1 stated to the police officer, “I will not do such thing anymore; I love this place.” A record review of facility’s “Resident Interview Form” dated 12/18/2025 at 3:45 PM indicated Resident 2 was interviewed by the DON and AD. The form indicated Resident 2 stated “I did it on my own, he put his pants down, so I started kissing and sucking his private area, but no sperm came out, nothing happened at all. I was not satisfied because no sperm came out and I am expecting that he will give me a hamburger and cheeseburger in return, but he did not.” During an interview on 12/19/2025 at 9:30 AM with CNA 1, CNA 1 stated on 12/18/2025 at around 2:15 PM, he was on his way back in the facility and saw from outside the glass window, Resident 1 standing in front of Resident 2. Resident 2 was sitting in the wheelchair holding the penis of Resident 1 and Resident 1’s penis was inside the mouth of Resident 2. CNA 1 also stated nobody else was in the hallway. During an interview with Resident 1 on 12/19/2925 at 10:39 AM, Resident 1 denied Resident 2 performing oral sex on him or that he asked anyone to perform oral sex. During an interview on 12/19/2025 at 12:20 PM with the DD, DD stated on 12/18/2025 OD witnessed from the patio / smoking area, through the glass window of the entrance of the facility that Resident 1 pulled down Resident 1’s pants, pulled out Resident 1’s penis and Resident 2 performed oral sex. During an interview on 12/19/2025 at 1:10 PM with Resident 2, Resident 2 stated she was not forced nor asked for any sexual favors. During an interview on 12/19/2025 at 5:22 PM, Registered Nurse (RN) 1 stated Resident 1 and 2’s oral sex was witnessed by CNA1 on 12/18/2025. RN 1 stated it was not acceptable even if the residents consented for it because it was in the hallway. During an interview on 12/19/2025 at 5:30 PM, the DON stated the facility failed to prevent the inappropriate sexual act/ sexual abuse between Resident 1 and 2 that happened on 12/18/2025. The DON also stated Resident 2’s care plan for the socially inappropriate / disruptive behavioral symptoms as evidenced by: touching and kissing hands of staff and residents with intervention to observe Resident 2 was not enough and not specific to the needs of the resident to ensure to prevent sexual abuse by or to Resident 2. The DON also stated that the facility did not have a policy for consented sexual relationship/ sexual acts between the residents in the facility. The facility is not able to provide documented evidence that Resident 1 and 2 consented to have an oral sex on 12/18/2025. A record review of the facility’s policy and procedures (P&P) titled, “Abuse Neglect (the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress), Mistreatment and Misappropriation of Resident Property (unlawful, intentional use or conversion of someone else's funds or assets for unauthorized purposes),” revised 10/2023, the P&P indicated it is essential for facilities to prohibit and prevent abuse, including sexual abuse, by staff to resident, resident to resident, visitor to resident. The facility failed to prevent sexual abuse for Resident 1 and 2 on 12 /18/2025. On 12/18/2025, OD and CNA 1 witnessed Resident 1 pulled down his (Resident 1) pants and pulled out his (Resident 1) penis. Resident 2 then performed oral sex to Resident 1. This failure resulted in exposure of Resident 1 and 2 to sexual abuse, risking emotional trauma or psychological trauma and the risk of placing other residents in the facility at risk for sexual abuse or psychological trauma. The above violations, jointly, separately or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious harm would result.