F835 in California. Pick another state for the same tag.
Against expectation — 2025
California cites F835 less often than its own record predicts
Versus expected share0.32×
0.32 times the national share — cited less often here than elsewhere.
Share of California citations0.09%
Of every deficiency written in California in 2025, this is the portion that was F835.
California0.09%
National0.29%
Share of all citations that were F835.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What California surveyors wrote
F835 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.
K · Immediate jeopardy, patternJune 9, 2023
46132
Based on observation interview and record review, the facility failed to:
1. Have a consistent leadership of an Administrator, DON (Director of Nursing), and DSD (Director of Staff Development), which led to the lack of training for the nursing staff for both the Licensed Nurses and the Certified Nursing Assistants (CNAs). These failures had the potential for the nursing staff's inability to provide accurate assessments and safe provisions of care to the residents to ensure residents received high quality of care and effective care was being delivered.
2. …
Based on observation, interview, and record review, the facility's Administrator failed to ensure effective oversight and necessary resources to ensure the residents' quality of care, safety, dignity, and dietary services, which include maintenance of the resident's nutrition and hydration were met to attain or maintain the highest practicable physical, mental, and psychosocial well-being for all 81 residents when:
1. The Quality Assurance and Performance Improvement Committee, whose members included the Administrator did not make sure an action plan was implemented to reduce the number of falls in the facility and promote a resident safety plan by monitoring trends and implementing changes through careful analysis of the falls, which led to 134 falls from January 2024 through May 2024. …
F · No harm, potential for more than minimal, widespreadJuly 10, 2026
Based on interview and record review the facility failed to:a. Ensure the Program Manager of the Behavioral Unit (PMBU) reported to the State Survey Agency (CDPH) and investigated an allegation of staff to resident sexual abuse (unwanted touch) for one out of six (Resident 35) sampled residents.b. Ensure the PMBU and the Director of Nursing (DON) reported an unusual occurrence (an unexpected or atypical event that deviates from the norm or expected pattern) of illicit drugs (substances that are illegal to manufacture, possess, sell, or use) being brought into the facility and possibly consumed by two out of six sampled residents (Resident 54 and Resident 79).c. Ensure the DON reported Resident 44's injury of unknown origin to CDPH and local law enforcement.Findings:a. …
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