Greenfield Care Center Of South Gate
GREENFIELD CARE CENTER OF SOUTH GATE in SOUTH GATE, CA — inspection on November 12, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During a concurrent interview and record review on 11/14/2025 at 3:15 p.m. with the Director of Staff Development (DSD), the facility's In-Service Binder, for 2025, was reviewed.
The DSD stated following the sexual abuse in June 2025, in-services and trainings were not provided to the facility staff because she was not notified of the incident.
The DSD stated staff should have been in-serviced and trained to prevent repeated sexual abuse, especially between two residents.
During a review of the facility's P&P titled Abuse and Neglect Prevention Management, dated 2/2018, the P&P indicated sexual abuse is a non-consensual sexual contact of any type with a resident.
The P&P indicated staff should manage the allegations by removing and protecting the residents and assessing the residents for injury and notifying the Admin.
The P&P indicated after the resident has been cared for, the licensed nurse should document the resident's condition each shift for 72 hours, update the care plan with identified actions that took place, updates the 24-hour report to alert following shifts to the allegations as well as the care plan updates and communicated specific care plan updates to direct care staff.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/12/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Greenfield Care Center of South Gate
8455 State Street South Gate, CA 90280
SUMMARY STATEMENT OF DEFICIENCIES
During a concurrent interview and record review on 11/12/2025 at 3:43 p.m. with the Admin, Resident 2's Progress Note, dated 6/13/2025, was reviewed.
The Admin stated he was the facility's Abuse Coordinator and licensed nurses should have informed him and the CDPH of the incident (alleged sexual abuse) between Resident 1 and Resident 2 on 6/13/2025, however was not done.
During an interview on 11/13/2025 at 9:20 a.m. with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated she saw Resident 2 kissing Resident 1's lips and laying in Resident 1's bed, on top of Resident 1, on 6/13/2025. CNA 2 stated she was a mandated reporter and should have reported the sexual abuse to the Admin and CDPH.During a review of the facility's P&P titled, Abuse and Neglect Prevention Management, dated 2/2018, the P&P indicated sexual abuse is non-consensual sexual contact of any type with a resident.
The P&P indicated all facility employees are required to report any known or suspected abuse immediately upon identifying a concern.
The P&P indicated all allegations of abuse will be reported to the Admin and the state survey and certification agency no later than two hours after the allegation is made.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/12/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Greenfield Care Center of South Gate
8455 State Street South Gate, CA 90280
SUMMARY STATEMENT OF DEFICIENCIES
dated 2/2018, Resident 1's Progress Notes, dated 6/2025, Resident 1's MDS, dated [DATE], and Resident 2's Progress Notes, dated 6/13/2025, were reviewed.
The DON stated the P&P indicated nonconsensual sexual contact of any type was sexual abuse.
The DON stated that both residents' progress notes indicated Resident 2 kissed Resident 1 and kissing was considered sexual contact.
The DON stated Resident 1's MDS indicated Resident 1 had severe cognitive impairment.
The DON stated Resident 2's MDS indicated Resident 2 had severe cognitive impairment.
The DON stated neither resident could consent to sexual contact and thus the nonconsensual kissing was sexual abuse and should have been investigated according to the P&P.
The DON stated Licensed Vocational Nurse 5 (LVN 5) notified her that Resident 2 kissed Resident 1 and climbed on top of him in his bed in the evening 6/13/2025.
The DON stated she did not instruct LVN 5 to investigate the incident.
The DON stated the incident on 6/13/2025 was not investigated because Resident 2 had forgotten the incident and there were no complaints from the residents or the resident representatives.
The DON stated the incident should have been investigated to prevent future sexual abuse.During a concurrent interview and record review on 11/12/2025 at 3:43 p.m. with the Administrator (Admin), Resident 2's Progress Note, dated 6/13/2025, was reviewed.
The Admin stated he was the facility's abuse coordinator and investigator.
The Admin stated he should have been notified about the incident described in the progress note but was not notified.
The Admin stated the incident was not investigated but should have been investigated to prevent future abuse.
During an interview on 11/13/2025 at 9:20 a.m. with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated she saw Resident 2 kissing Resident 1's lips and laying in Resident 1's bed, on top of Resident 1, on 6/13/2025. CNA 2 stated she never investigated the incident, never provided a written statement, and was never interviewed about the incident by any facility staff.During a review of the facility's P&P titled Abuse and Neglect Prevention Management, dated 2/2018, the P&P indicated sexual abuse is non-consensual sexual contact of any type with a resident.
The P&P indicated resident-to-resident altercations are investigated in an objective, timely, and complete manner.
The P&P indicated all allegations of abuse will be investigated and the written findings of the investigation will be reported to the department of public health within five days of the alleged occurrence.
Facility ID: