F0609

E

Failure to Report Allegations of Sexual and Physical Abuse to CDPH

Lawndale, California Survey Completed on 01-21-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to report allegations of sexual and physical abuse to the California Department of Public Health (CDPH) as required by policy and regulation. On 12/19/2025, a resident with dementia, hemiplegia/hemiparesis, depression, and anxiety, who lacked capacity to consent but was usually able to understand and be understood, reported that another resident entered her room, removed his pants, removed her pants, kissed her face, and touched her vagina. An SBAR dated 12/19/2025 documented that this resident was exposed to inappropriate behavior by the alleged perpetrator. A CNA observed the alleged perpetrator in the resident’s room lowering his pants, and the resident reported to the CNA and RN Supervisor that her vagina had been touched. The RN Supervisor reported the incident to the DON.

The same day, another resident, who had muscle weakness and low back pain and had capacity to understand and make decisions, reported that the same alleged perpetrator entered his room, stated he wanted to suck the resident’s penis, attempted to pull off his blankets to expose him, and, when unsuccessful, hit him on the right leg three times. A Change in Condition Evaluation dated 12/19/2025 documented that this resident reported being struck on his legs three times by the other resident. CNA 3 stated that the resident told her about the sexual statement and being hit, and she reported this to LVN 1. LVN 1 confirmed that the resident reported being hit on the leg and being asked if the alleged perpetrator could suck his private part. The facility’s records for the alleged perpetrator showed schizoaffective disorder, behavioral symptoms including public sexual acts and disrobing, and an SBAR documenting that he entered the first resident’s room, lowered his pants, and exhibited sexually inappropriate behavior.

Despite these documented allegations and staff reports, the DON stated she did not report the incidents to CDPH because she believed that the described behaviors (exposing private parts and hitting on the leg) were not considered abuse. The Administrator stated he was informed of both incidents on 12/19/2025 and did not report them to CDPH. Facility policies titled “Abuse Prevention and Management” and “Abuse-Reporting and Investigations” defined abuse to include physical and sexual abuse and required that all allegations of abuse and criminal activity be promptly reported, with the Administrator or designee submitting a written SOC 341 report to CDPH Licensing and Certification within two hours. The failure of the DON and Administrator to report these allegations to CDPH constituted the cited deficiency.