The administrator thought the infection preventionist had reported it. The infection preventionist thought another infection preventionist had reported it. The director of nursing claimed they had reported it but couldn't provide any documentation. The second infection preventionist said she didn't know they were supposed to report it at all.
Federal inspectors discovered the breakdown during a September complaint investigation. Resident 3 tested positive on August 13. Resident 5 tested positive on August 15. Resident 4 tested positive on August 16.
The facility's own policy required immediate reporting to state health officials. The undated policy stated the administrator "will be responsible for reporting to the Department of Public Health and local public health officer a single case of a communicable disease requiring immediate reporting."
But when inspectors interviewed the administrator on September 11, she admitted she hadn't reported the outbreak because "she thought the facility's IP had reported the COVID-19 positive residents to CDPH."
The first infection preventionist told inspectors at 12:45 PM that same day she hadn't notified state health officials "because IP 1 thought IP 2 had notified CDPH regarding Resident 1, 4, and 5's positive COVID-19 status."
Five minutes later, the director of nursing insisted to inspectors that "the Department of Public health and the Public Health Nurse had been notified." She said the outbreak consisted of three people.
No documentation existed.
When inspectors asked for proof the state had been notified, the director of nursing couldn't provide any. The inspection report notes: "No document could be provided by DON indicating the Department of Public Health had been notified."
The second infection preventionist, interviewed at 1:30 PM, acknowledged she hadn't reported the outbreak either. She told inspectors she didn't know "that the facility had to report the COVID-19 cases to CDPH."
Her admission revealed the cost of the failure. She told inspectors that by not reporting the cases, "there would be a lack of outbreak support" from state health officials.
The facility's own written policy defined exactly what constituted a reportable outbreak: "one or more facility acquired COVID-19 case in a resident and/or three or more suspect, probable or confirmed COVID-19 cases." With three confirmed cases, Ararat clearly met the threshold.
The policy emphasized that outbreaks "are identified, handled, and reported as required" and that "outbreaks of communicable diseases within the Facility was promptly identified an appropriated treated and reported."
It specifically named the administrator as responsible "for reporting to the Department of Public Health, which included facility outbreak of COVID-19."
The first infection preventionist acknowledged during her interview that since the three residents were symptomatic and tested positive, "the facility should have reported the positive COVID-19 residents to the California Department of Public Health."
The administrator also admitted during her interview that "the facility had a COVID-19 outbreak and stated that CDPH should have been notified regarding the COVID-19 outbreak."
But the acknowledgments came only after federal inspectors arrived to investigate. For nearly a month, from mid-August through early September, California health officials remained unaware that Ararat Convalescent Hospital was experiencing a COVID outbreak.
The breakdown occurred despite the facility having two infection preventionists specifically tasked with monitoring and reporting communicable diseases. The policy required reporting "communicable disease data to CDPH" for any outbreak.
State health departments use outbreak reports to provide technical assistance, coordinate testing, and help facilities implement infection control measures. Without notification, Ararat operated without that support during its outbreak.
The inspection found the facility violated federal requirements for infection prevention and control. Inspectors cited the facility for failing to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment.
Three residents contracted COVID-19. The state health department that could have provided outbreak support never knew about it. And when federal inspectors asked who was supposed to make the required report, four different staff members gave four different answers.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ararat Convalescent Hospital from 2025-09-11 including all violations, facility responses, and corrective action plans.