West Hills Health and Rehab: Sexual Abuse Unreported - CA
She was wrong. And inspectors who arrived days later found the report had never been made.
The incident happened on the evening of December 17, 2025. According to what Resident 1 told staff the following morning, Resident 2 had come into her room and tickled her foot. She was crying when she disclosed it. She also told the certified nursing assistant who first heard the account that she believed Resident 2 had wanted to have sex with her.
The CNA brought the report to LVN 1 at around 8 a.m. on December 18. LVN 1 went directly to Resident 1's room to ask what had happened. Resident 1 repeated what she had told the CNA: Resident 2 had come into her room the night before and tickled her foot. LVN 1 asked whether Resident 2 had touched her anywhere else. Resident 1 said no. Then she added that she thought Resident 2 had wanted to have sex with her.
LVN 1 brought it immediately to RN 1. She described her reasoning plainly when inspectors interviewed her on December 22: Resident 2 had touched Resident 1 without Resident 1's consent. That, to LVN 1, made it possible sexual abuse.
RN 1 agreed. When inspectors spoke with her that same afternoon, RN 1 said Resident 2 had no right to tickle or touch anyone without consent. She called it a type of sexual abuse. She said it was her professional opinion that the alleged tickling constituted alleged sexual abuse, which was why she escalated it to the administrator, who also served as the facility's designated abuse coordinator.
That conversation happened at approximately 8:45 a.m. on December 18. By 9 a.m., the administrator had been told everything: the nighttime entry into the room, the unwanted touching, and Resident 1's belief about what Resident 2 had intended.
The administrator made a decision. She did not think the tickling was sexual in nature. Because she did not believe it was sexual, she did not report it as an allegation of sexual abuse to the California Department of Social Services, the local ombudsman, adult protective services, law enforcement, the resident's physician, the facility's medical director, or Resident 1's representative. She told inspectors that if she had believed it was sexual in nature, she would have reported it. She did not believe that, so she did not.
The facility's own written abuse policy, last reviewed on January 8, 2025, described what was supposed to happen when abuse or suspected abuse was identified. All reports of resident abuse were to be reported to local, state, and federal agencies and thoroughly investigated. If abuse was suspected, the suspicion itself was to be reported immediately, to the administrator and to other officials under state law. The administrator was then responsible for contacting the state licensing and certification agency, the ombudsman, the resident's representative, adult protective services, law enforcement, the attending physician, and the medical director.
The administrator is the abuse coordinator. The policy she was responsible for enforcing listed her as the person who triggers every one of those notifications. On December 18, she received a report from a registered nurse who told her directly that the incident was, in the nurse's professional opinion, sexual abuse. The administrator weighed that assessment and set it aside.
What is striking about the inspection record is not that there was disagreement about how to categorize what happened. Reasonable people, including clinicians, sometimes see the same event differently. What is striking is the sequence: a nursing assistant heard the report and immediately escalated it. A licensed vocational nurse heard it and immediately escalated it, describing her reasoning clearly. A registered nurse heard it, called it sexual abuse, and immediately escalated it. At each step, the person receiving the information treated it seriously and moved it up the chain.
Then it reached the top of the chain, and it stopped.
The administrator, speaking to inspectors on December 23, did not dispute the facts of what was reported to her. She confirmed she had been told about the nighttime entry, the unwanted touching, and Resident 1's stated belief about Resident 2's intentions. Her explanation for not reporting was not that she had investigated and found the allegation unsubstantiated. It was that she had decided, in the moment, that the touching was not sexual in nature, and that determination ended her obligations.
But the facility's own policy does not require a determination that abuse occurred before reporting is triggered. It requires only that abuse be suspected. RN 1 had told the administrator explicitly that she suspected sexual abuse. That suspicion, under the policy the facility had written and reviewed eleven months earlier, was supposed to be enough.
Inspectors classified the violation as causing minimal harm or potential for actual harm, with few residents affected. The complaint inspection was completed on December 23, 2025.
Resident 1 had been crying the morning after it happened. She had told three different staff members, in three separate conversations, what she experienced and what she feared. Each of those staff members had taken her seriously. The administrator had not, and so the agencies responsible for protecting residents like Resident 1 were never told that anything had happened at all.
The state licensing agency. The ombudsman. Adult protective services. Law enforcement. Her doctor. Her family or representative. None of them received a call. None of them knew.
Resident 1 still lived in the same facility as Resident 2 when inspectors arrived five days later.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for West Hills Health and Rehabilitation Center from 2025-12-23 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
WEST HILLS HEALTH AND REHABILITATION CENTER in CANOGA PARK, CA was cited for abuse-related violations during a health inspection on December 23, 2025.
And inspectors who arrived days later found the report had never been made.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.