Maclay Healthcare Center in Sylmar: Inspection Record Review, Complaints and Abuse Reports (Updated October 30, 2026)

According to the citation, Resident 1 was an 83-year-old woman with severely impaired cognition, one-sided paralysis after a stroke, and muscle weakness. Her care plan and assessment stated she depended fully on staff to turn and reposition in bed, and an interdisciplinary team note said she was at higher risk of falls during repositioning and of bleeding because she took a blood thinner.

CDPH found that on June 27, 2026, at about 9:35 a.m., CNA 1 repositioned Resident 1 during a bed bath with no help from another staff member, although facility policy and her care plan called for two or more nursing staff. Inspectors found that she rolled off the bed and fell face down to the floor. According to the citation, she had a bleeding abrasion on the back of her head, a bump over her right eye, and a cut on her left big toe. She was sent to a hospital, where she was diagnosed with a soft tissue hematoma (a pool of blood under the skin) above the right eye, and her cuts were closed with nine staples.

The department issued a Class A citation for patient care, with a $25,000 penalty that was trebled to $75,000. The federal 2567 report from the same investigation cited F689, the rule on keeping residents free of accident hazards and providing adequate supervision, at severity level G, which means actual harm to a resident.

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According to the citation, Resident 1 was a 61-year-old woman with orthostatic hypotension (a drop in blood pressure when standing up that can cause dizziness), difficulty walking, muscle weakness, and a history of falls. A fall risk evaluation rated her a high risk for falls, and her physician orders called for staff to monitor her for postural blood pressure drops linked to her medications.

CDPH found the facility failed to monitor her orthostatic blood pressure as the physician ordered, failed to make sure she wore nonskid footwear when walking, and failed to make sure she used her assistive device. Inspectors found that on April 25, 2026, at 1:55 a.m., she fell while walking in the hallway without the device and wearing personal slip-on slippers. According to the citation, she reported severe pain in her left shoulder and arm and was left on the floor until paramedics arrived.

The 2567 report states that a hospital diagnosed a closed displaced fracture at the top of the left upper arm bone (humerus) and a closed displaced fracture of the left big toe. Her arm was placed in a shoulder immobilizer and her toe was buddy-taped. The department issued a Class A citation for patient care, with a $25,000 penalty that was trebled to $75,000. The federal survey cited F689, which covers accident hazards, supervision and assistive devices, at severity G, meaning actual harm.

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CDPH found during its annual recertification survey in January 2026 that three residents with physician orders for a pureed diet (smooth food that is easy to swallow) were served regular oatmeal with lumps and grains on January 13, 2026. According to the citation, the kitchen did not follow the pureed oatmeal recipe or the IDDSI Level 4 texture standard. Inspectors saw no pureed oatmeal on the steam table, and Cook 1 told them she had made only regular oatmeal. One of the residents had dysphagia (difficulty swallowing) and a speech therapy plan calling for pureed food.

The department determined this placed the three residents at risk of being unable to eat safely, of choking, and of aspiration (food entering the airway and lungs). The 2567 report states that inspectors also found 16 residents on soft bite-sized diets were given finely chopped and minced food, and pureed pancakes and sausages that did not meet texture tests. The survey agency called an immediate jeopardy on January 14, 2026, in the presence of the administrator and the director of nursing.

According to the 2567 report, the facility's immediate jeopardy removal plan included chest x-rays for the three residents, which showed clear lungs, one-on-one training for the cook, dietary staff, nurses and CNAs, a facility-wide audit of residents on pureed diets, and a new three-step tray check. CDPH issued a Class A citation with a $20,000 penalty. The federal survey cited F805, food prepared in a form to meet individual needs, at severity K, the immediate jeopardy level.

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According to the citation, on March 16, 2025, at 8:26 a.m., Resident 1 and Resident 2 were on the facility's smoking patio when a verbal argument turned physical and Resident 2 used a knife he had with him to injure Resident 1. CDPH found the facility failed to protect residents from physical abuse and failed to provide supervision. The citation notes the knife was not found.

Inspectors found Resident 1, an 85-year-old man with dementia, had abrasions on both knees and a 3-centimeter cut on his left thumb that needed eight stitches at a hospital. His care plan noted a history of a physical altercation with another resident and stated he would not smoke without supervision. Resident 2 had an abrasion on his left hand and wrist and was sent to a hospital for further evaluation. The 2567 report states the survey agency called an immediate jeopardy on March 19, 2025.

The 2567 report states the facility's immediate jeopardy removal plan included a one-on-one sitter for Resident 2, emotional support visits for Resident 1, staff education on abuse prevention and supervision of the smoking schedule, "No Weapons Allowed" signs, and efforts to locate the knife. Local police came to the facility and took Resident 2 into custody. The department issued a Class A citation for patient rights, with a $25,000 penalty trebled to $75,000. The federal survey cited F689 (accident hazards and supervision) and F600 (freedom from abuse and neglect), both at severity J, and F610 (investigating and correcting alleged violations) at severity D.

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The 2567 report states that on October 17, 2024, at 7:30 p.m., CNA 4 heard Resident 9 yelling and found him sitting in his wheelchair watching television while his roommate, Resident 10, held an arm around his neck from behind and punched him in the face several times with a closed fist. Inspectors found the facility failed to protect Resident 9's right to be free from physical abuse.

According to the report, Resident 9 had severely impaired cognition and aphasia (difficulty speaking) after a stroke-related condition. He had swelling and bleeding of the lips, rated his pain 5 out of 10, and was treated with an ice pack. The inspectors found that Resident 10's care plans, dating back to January 2023, described aggressive behavior, mood swings and poor impulse control, and that his medication record showed two anger outbursts three days before the incident. The staff separated the two residents, and the physician was notified at 8:41 p.m.

The inspectors cited F600, the federal rule on freedom from abuse and neglect, at severity G, which means actual harm to a resident. The report states that, using the reasonable person concept, a person subjected to this kind of abuse may experience pain, hopelessness, helplessness and humiliation. The full narrative is in the linked report.

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The 2567 report states that on October 8, 2024, Resident 135, who was allergic to onions, was served baked beans containing onions for lunch. Inspectors found the facility failed to make sure this resident was not given food containing a known allergen. According to the report, the resident had been admitted a week earlier, had severely impaired cognition, and had lung disease and high blood pressure.

The inspectors determined this had the potential to cause a life-threatening reaction such as anaphylactic shock (a severe allergic reaction that can close the airway) or cardiac arrest. The state survey agency called an immediate jeopardy that afternoon in the presence of the administrator and the director of nursing. The report states a licensed vocational nurse assessed the resident that day and saw no allergic reaction, and the physician was notified.

According to the 2567 report, the facility's immediate jeopardy removal plan included green meal tray cards and green non-removable arm bands for residents with food allergies, a posted allergy list in the kitchen in English and Spanish, staff training and daily huddles, daily tray audits at every meal and snack, nurse checks of trays before serving, and a new menu system tied to electronic health records. Inspectors verified the plan and removed the immediate jeopardy on October 11, 2024. The survey cited F806, which covers food that accommodates allergies, intolerances and preferences, at severity J, the immediate jeopardy level.

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According to the citation, on May 26, 2024, at 8:45 p.m., CNA 2 and CNA 3 heard Resident 1 yelling for help. They went to his room and found his roommate, Resident 2, on top of him, kissing his neck and pulling his jeans down to his knees. Resident 1 asked the CNAs to remove Resident 2 because he was kissing and touching him. CDPH determined the facility failed to protect Resident 1's right to be free from sexual abuse, failed to implement policies that would have prevented it, and failed to make sure he was treated with dignity and respect.

The citation states Resident 1 was a 73-year-old man with end-stage heart failure and one-sided weakness after a stroke, who needed maximum help with dressing and walking and had intact cognition. Inspectors found that after the incident he experienced shock, shaking, hyperventilation (rapid breathing) and depression that required medication, withdrew from social activities and said he wanted to leave the facility.

According to the citation, staff placed Resident 2 on one-to-one monitoring and notified the physician, administrator, director of nursing and local police. Paramedics came, but Resident 1 refused to be transferred out. The department issued a Class A citation for patient rights, with a $15,000 penalty trebled to $45,000. The federal survey cited F600, freedom from abuse and neglect, at severity J, the immediate jeopardy level, and F610, investigating, preventing and correcting alleged violations, at severity D.

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According to the citation, Resident 1 was a 70-year-old man admitted on November 2, 2023, with pneumonia, chronic kidney disease and an enlarged prostate. He had an indwelling urinary catheter (a tube that drains urine from the bladder) because of urinary retention (being unable to empty the bladder). On November 3, the catheter was accidentally pulled out, and his physician ordered it discontinued and told staff to monitor him for urinary retention for 72 hours.

CDPH found the facility failed to monitor how much urine he passed during that period, failed to tell the physician it had no policy on measuring urine output for incontinent residents, and did not use its bladder scanner because there was no policy for it and the nurses had not been trained on it. Inspectors found the progress notes and the 72-hour toileting diary had no record of his urine output, and his incontinence briefs were not weighed to estimate the volume.

The citation states that on November 14, 2023, a urologist saw him for a swollen abdomen and drained 8 liters of urine from his bladder, which the document notes holds about 700 milliliters in men. He was sent to a hospital emergency room and diagnosed with obstructive uropathy (blocked urine flow), likely from the enlarged prostate, and acute kidney injury. The department issued a Class A citation for patient care with a $25,000 penalty. The federal survey cited F684, quality of care, at severity G, meaning actual harm.

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According to the citation, Resident 1 was a woman with vascular dementia, difficulty walking and muscle wasting who had fallen in May 2023 and was rated a high fall risk. Her physician ordered a sensor pad alarm in her bed to alert staff when she got up. CDPH found the facility failed to provide a safe environment and supervision to prevent further falls.

Inspectors found that on June 23, 2023, at 10:40 a.m., she walked out of her room unsupervised and unassisted, became dizzy and fell in the hallway, cutting the left side of her forehead. She was sent to a hospital and returned the next morning at 7:17 a.m. About an hour later she fell again in her room while walking alone, and the forehead cut reopened and bled. She was taken to a second hospital, where she was diagnosed with a fracture of the C2 vertebra in her neck and a hard cervical collar was recommended.

The citation states CNA 3 told inspectors she heard the bed alarm, saw the resident about three steps away and could not reach her in time, and that the resident's room was not near the nursing station. The assistant director of nursing told inspectors the resident could have been given one-to-one supervision because of how often she fell, and that not moving her closer to the nursing station placed her at risk. The department issued a Class A citation for patient care, with a $20,000 penalty trebled to $60,000. The federal survey cited F689, accident hazards and supervision, at severity G, meaning actual harm.

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The 2567 report states that on September 16, 2023, at about 9 a.m., Resident 1 was sitting on his bed in a four-bed room when a roommate, Resident 2, wheeled himself over, took the metal footrest off his wheelchair, stood up and tried to hit Resident 1 with it. Resident 1 held Resident 2's arm to block the footrest, and Resident 2 then hit him several times with his other hand. Inspectors found the facility failed to make sure Resident 1 was free from physical and mental abuse.

According to the report, CNA 4 and CNA 5 were inside the room with another resident and did not step in right away. A licensed vocational nurse heard the screaming, came in, took the footrest away and separated the residents. Resident 1 told inspectors he saw two staff members watching and that they did not help him. The CNAs gave inspectors their own accounts, and CNA 5 said he grabbed Resident 2's arm. Resident 2, who had Alzheimer's disease, was moved to another room that day.

Inspectors found Resident 1 had two skin tears, about 1 centimeter each, on his left hand and forearm. The report states he was afraid for his life, felt intimidated and could not sleep that night, worried Resident 2 would come back. The survey cited F600, freedom from abuse and neglect, at severity G, meaning actual harm, and F607, developing and implementing abuse and neglect policies, at severity D.

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The 2567 report states that on August 20, 2023, at 6:38 p.m., Resident 1 wheeled himself out of an exit door near Station 1 to the smoking patio without anyone noticing. He had a fall that no one saw and was out in the rain for 13 minutes until staff brought him back inside at 6:51 p.m. According to the report, this happened during Hurricane Hilary. Resident 1 had one-sided paralysis after a stroke, severely impaired cognition, and was assessed as at risk for wandering and at high risk for falls.

Inspectors found the facility failed to monitor where he was and supervise him, failed to make sure his wander guard bracelet (a device that sets off an alarm near exits) triggered the alarm, failed to check that the bracelet worked, failed to make sure the exit door alarm went off, and failed to monitor the surveillance cameras. The report states this placed him at high risk for hypothermia (body temperature that drops too low) from staying wet and cold.

The state survey agency called an immediate jeopardy on September 4, 2023, and removed it on September 7 after checking the facility's removal plan. According to the 2567 report, that plan included keeping him in highly visible areas, daily checks of all exit door alarms, checks of wander guards every shift, staff training on supervision, neglect and accident hazards, and daily review of door alarm logs by the administrator for 30 days. The survey cited F600 (freedom from abuse and neglect) and F689 (accident hazards and supervision), both at severity J, the immediate jeopardy level.

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