The incident came to light on December 18, 2025, when Resident 1 became agitated about her blood pressure medication and told Registered Nurse Supervisor 1 that she was being harassed and had been assaulted by Resident 2. The resident was upset enough to call police herself, and officers arrived at Pasadena Grove Health Center that same day to speak with her.
Nobody reported the assault allegation to state authorities.
RNS 1 admitted during a December 19 inspection interview that she should have reported the incident to three state agencies immediately or within two hours after Resident 1 told her about it. "It was important to report the incident to the three state agencies to protect and ensure the safety of the residents and to prevent further abuse," RNS 1 told inspectors. She acknowledged she did not follow the facility's abuse policy.
The facility's own policy, revised in August 2023, requires staff to "report allegations of abuse immediately but no later than 2 hours after forming the suspicion" to the state survey agency, adult protective services, law enforcement, and the Ombudsman. Licensed Vocational Nurse 1 confirmed this was facility policy during the inspection, stating reports should go to the abuse coordinator and three state agencies "right away or within two hours of the incident."
The Director of Nursing saw police arrive at the facility on December 18 but never asked why they were there. He told inspectors that RNS 1 informed him that Resident 1 had called and spoken to police, but RNS 1 never told him that Resident 1 had reported harassment and assault by another resident.
"I did not know the reason for the police visit and did not ask Resident 1 or RNS 1 for the reason for the police visit," the DON said during his December 19 interview.
The Social Services Director was also kept in the dark. She learned about the assault allegation only when reviewing Resident 1's progress note dated December 18, which indicated Resident 1 was assaulted by Resident 2 and had called police and the California Department of Public Health. The progress note did not specify when the assault occurred.
"I was not informed that on 12/18/2025, Resident 1 reported getting assaulted by Resident 2 to RNS 1," the Social Services Director told inspectors. She also was not informed that police had come to speak with Resident 1 that day.
The Social Services Director emphasized the importance of proper reporting. "Resident 1's abuse allegation should have been reported to the State Agencies immediately or within two hours after the allegation was reported," she said. "It was important to report abuse to the State Agencies to have documentation of what took place and to ensure the safety of the residents involved."
The DON echoed this concern during his interview. "If there is any report of suspected abuse, it should be reported to the State Agencies within two hours," he said. "It was important to report suspected abuse to the abuse coordinator, CDPH, Ombudsman, and police so an investigation can be started, prevent future abuse in the facility, and for the safety of the residents."
The facility's Abuse Prevention and Prohibition Program policy states its purpose is "to ensure the facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for prevention, identification, investigation, and reporting of abuse."
The policy specifically requires reporting allegations of abuse immediately but no later than two hours after forming the suspicion "if the alleged violation involves abuse or results in serious bodily injury to the state survey agency, adult protective services, law enforcement, and the Ombudsman."
Despite having this clear policy and multiple staff members understanding the reporting requirements, the facility failed to act when Resident 1 reported the assault. The breakdown occurred at multiple levels: the nurse who received the report didn't make it, the Director of Nursing didn't inquire about why police were at the facility, and the Social Services Director wasn't informed of the incident until reviewing records the next day.
The inspection found that few residents were affected by this violation, and the level of harm was classified as minimal harm or potential for actual harm. However, the failure to report represents a systemic breakdown in the facility's abuse prevention program at a critical moment when a resident was seeking help.
Resident 1 took matters into her own hands by calling police directly, but the facility's failure to follow its own reporting procedures meant that other required agencies were not notified within the mandated timeframe. This delay potentially compromised the investigation and left other residents at risk if the alleged harassment and assault were ongoing.
The inspection revealed that staff understood the importance of reporting but failed to execute the policy when it mattered most. RNS 1's admission that she did not follow facility policy, combined with the DON's failure to investigate why police were at the facility, demonstrates a concerning gap between policy and practice at Pasadena Grove Health Center.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pasadena Grove Health Center from 2025-12-19 including all violations, facility responses, and corrective action plans.