Based on observations (video surveillance), interviews and record review, the facility failed to protect the residents' right to be free from physical abuse by for one of eight sampled residents (Resident 1) when Resident 1 physically attacked and strangled Resident 2 leading to Resident 2's death. Also, the facility failed to take additional steps to prevent further potential abuse from occurring when staff allowed Resident 1 to leave the room and encounter other residents (Residents 3, 4, 5, 6, 7, and 8) without providing supervision and monitoring of Resident 1. These deficient practices resulted in the death of Resident 2 by Resident 1 on 8/1/2026 at approximately 7:15 p.m., when staff found Resident 1 strangling Resident 2. …
F600 citations in California
Abuse and neglect · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
California cites F600 less often than its own record predicts
0.76 times the national share — cited less often here than elsewhere.
Of every deficiency written in California in 2025, this is the portion that was F600.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What California surveyors wrote
F600 findings written in California, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on observation, interview, and record review, the facility failed to protect two of two resident's (Resident 1 and Resident 2) right to be free from physical abuse by a resident when, Resident 3, who had a history of known violent behaviors, entered the common area of the facility and pushed Resident 2 on 8/11/26 and on 8/12/26 walked up to Resident 1, slapped her on the face and pushed her to the ground.This failure resulted in Resident 1 feeling angry about the incident and Resident 2 sustaining bruising, pain, and a fracture (broken bone) of her right arm. …
Based on observation, interview, and record review, the facility failed to ensure that one out of 13 residents (Resident 35) was free from abuse when the facility did not recognize, report, assess, or follow up on repeated allegations and documented incidents involving physical contact, yelling, screaming, and disruptive behaviors from a roommate (Resident 32). These failures resulted in ongoing fear, sleep disruption, and psychosocial distress for Resident 35.During an observation on 08/24/2026 at 10:59 AM in the shared room of Resident 32 and Resident 35, Resident 32 began yelling and screaming when the surveyor entered the room. …
The short window
Recent years
| Year | Share of California citations | vs expected |
|---|---|---|
| 2023 | 1.77% | 1.00× |
| 2024 | 2.15% | 0.91× |
| 2025 | 1.97% | 0.76× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else California surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction