Based on observation, interview and record review, the facility failed to protect residents in the facility from physical abuse when Certified Nursing Assistant 1 (CNA1) deliberately poked one resident (Resident 1) in the right cheek, smacked Resident 1 in the hand and then forced Resident 1 down in her wheelchair causing Resident 1 to cry out. The facility failed to protect 16 residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16) assigned to CNA1, from possible physical abuse when the Administrator (ADM) returned CNA1 to direct care duty before completion of a thorough abuse investigation, including interviewing all witnesses. …
F610 citations in California
Investigating alleged violations · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
California cites F610 less often than its own record predicts
0.41 times the national share — cited less often here than elsewhere.
Of every deficiency written in California in 2025, this is the portion that was F610.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What California surveyors wrote
F610 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 observations, interviews, and record reviews, the facility failed to identify and ensure that two out of three sampled residents (Resident 1 and Resident 2), were protected from sexual abuse (non-consensual sexual contact of any type with a resident). Resident 1 reported to staff members being sexually abused during care provided by Certified Nurse Assistant (CNA) 1. CNA 1 was not removed from the staffing schedule and was allowed to continue to care for other residents in the facility. These failures in a delay in implementing protective and preventative action resulted in Resident 2 experiencing sexual abuse. …
Based on interview and record review, the facility failed to ensure allegations of misappropriation of resident property were investigated, the findings of the investigations were reported to the appropriate parties, and protective measures were put in place to prevent further abuse for one of three sampled residents (Resident 4) when the facility was unable to provide evidence that the allegation of misappropriation of property for Resident 4 was investigated thoroughly and results of the investigations were reported to the Department and other appropriate parties.These failures had the potential to place Resident 4 and other residents in the facility at risk for further misappropriation of resident property and a negative psychosocial outcome (the changes in a person's mental health,… …
The short window
Recent years
| Year | Share of California citations | vs expected |
|---|---|---|
| 2023 | 0.69% | 0.54× |
| 2024 | 0.74% | 0.52× |
| 2025 | 0.62% | 0.41× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else California surveyors cite →
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