Novato Healthcare Center

Based on interview and record review, the facility failed to ensure an allegation of abuse was reported within the required timeframe for two of two sampled residents (Resident 1 and Resident 2) when no documentation was received by the Department of Public Health (the Department) until four days after the alleged abuse occurred.This failure of timely reporting had the potential to cause a delayed response by enforcement agencies to ensure resident safety.Findings:A review of a facility document titled Investigation Summary of Resident 1 and Resident 2 dated 7/17/25 and received by the Department on 7/17/25, indicated Resident 1 made verbal threats towards Resident 2 on 7/13/25.

During an interview on 8/19/25 at 12:12 p.m., the Administrator (ADM) stated it was the facility's policy to report an allegation of abuse to the Department within two hours.

The ADM confirmed the facility sent the five-day follow up report to the Department on 7/17/25 for an incident of alleged abuse on 7/13/25.

During an interview on 8/19/25 at 12:30 p.m., Licensed Nurse A (LN A) stated he faxed a State of California Report of Suspected Dependent/Elder Abuse (referred to as the SOC 341) to the Department on 7/13/25 but could not recall the time. LN A stated he did not get confirmation the fax was sent to the Department. LN A stated the facility policy was to report allegations of abuse within two hours.

During an interview on 8/19/25 at 12:58 p.m., Licensed Nurse B stated he witnessed an incident of verbal abuse between Resident 1 and Resident 2 on 7/13/25 at 4:30 p.m. LN B stated facility protocol was to notify the Department within two hours of any incident of alleged abuse. LN B stated he called the Department at 7:18 p.m. and left a voice message. A record review of the Department's voice mail log dated 7/11/25 through 7/14/25 indicated no voicemails were received from any staff from the facility regarding an allegation of abuse between Resident 1 and Resident 2.During an interview on 8/20/25 at 12:50 p.m., the ADM stated the expectation was for staff to respond immediately to any resident-to-resident altercations and report to the Department within two hours.

The ADM verified there was not a fax confirmation of an SOC 341 sent to the Department on 7/13/25.

The ADM confirmed there was no proof that a phone call was made to the Department to report the incident on 7/13/25.

The ADM stated if a phone call had been made on 7/13/25 at 7:18 p.m. for an incident which occurred on 7/13/25 at 4:30 p.m., it would not have been within the two-hour reporting timeframe.A record review of the facility's policy titled, Abuse Prevention and Management and dated 5/30/24 indicated, The administrator or designated representative will.send a written SOC 341 report to. CDPH Licensing and Certification within two hours.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

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