Intercommunity Care Center in Long Beach: Inspection Record Review, Complaints and Abuse Reports (Updated October 30, 2026)

According to the citation, CDPH made an unannounced visit on August 4, 2026, to investigate a complaint and a facility-reported incident about an altercation between two residents. CDPH determined that Resident 1, a 67-year-old woman, physically attacked and strangled Resident 2, a 78-year-old woman who shared her room, and that Resident 2 died. The citation states that on August 1, 2026, at about 7:15 p.m., CNA 1 entered the room and found Resident 1 pulling a shoelace tight around Resident 2's mouth and neck. Staff separated the residents, started CPR (cardiopulmonary resuscitation) and called paramedics.

Inspectors found the facility failed to protect Resident 2 from abuse by Resident 1 and did not follow its own policies on abuse prevention and on residents whose behavior puts others at risk. According to the 2567 report, after the attack Resident 1 was allowed to move about the building without supervision for 21 minutes. She sat with six other residents in the activity and dining room until her arrest. Inspectors identified an immediate jeopardy (a situation likely to cause serious harm or death) on August 6, 2026.

CDPH issued a Class A citation with a $60,000 penalty. The federal report cites F600 (severity J), on freedom from abuse and neglect, and F609 (severity D), on reporting of alleged violations. According to the 2567 report, the facility's plan to remove the immediate jeopardy included retraining the nurses and CNAs involved, a new rule that a resident who assaults another must stay under direct supervision until police or emergency responders take over, and hourly safety rounds. Inspectors removed the immediate jeopardy on August 12, 2026.

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According to the citation, CDPH made an unannounced visit on January 21, 2026, to investigate a facility-reported incident about resident safety. Resident 1 was a 68-year-old woman with dementia and an abnormal gait. Her assessments showed severely impaired decision-making, that she needed supervision for walking, and that she used a front-wheeled walker.

CDPH found the facility failed to develop and carry out an individualized fall prevention care plan for her, including reminders to use her walker and to call for help before walking. Inspectors also found the facility did not follow its own policy that makes the interdisciplinary care team responsible for each resident's individualized care plan. According to the citation, on January 6, 2026, at 9:40 p.m., staff saw Resident 1 walking in a hallway without her walker. She suddenly started running and fell on her left side. The next morning she rated her hip pain 10 out of 10. An X-ray showed an acute fracture of the left thigh bone (femur), and she was sent to a general acute care hospital. Hospital records reviewed by inspectors show she had a hemiarthroplasty (surgery to replace the ball of the hip joint) on January 8, 2026.

CDPH issued a Class A citation with a $25,000 penalty. The federal 2567 report cites F656 (severity G), on developing and implementing a comprehensive care plan, and states the failures led to the fall and the fracture.

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According to the citation, CDPH received a facility-reported incident on January 31, 2025, about a resident found on the ground on the facility's outdoor patio, and investigated on February 14, 2025. Resident 1 was an 84-year-old man with dementia and severe cognitive impairment who was assessed as high risk for falls. He had broken his left hip in a fall at the facility in March 2024.

CDPH determined that on January 23, 2025, Resident 1 opened a patio exit door that had a sensor alarm and went outside alone, and staff did not respond to the alarm. Video reviewed by inspectors showed him walking on the patio without his walker. At 2:39 p.m. he tried to sit in a chair, missed it and fell. A nursing note written at 3:30 p.m. states he was found on the patio and could not move. A hospital diagnosed a right hip fracture. Inspectors found the facility failed to supervise him, did not keep continuous supervision on the patio, and did not update his care plan after the earlier fall.

CDPH issued a Class A citation and trebled the $25,000 penalty to $75,000. The federal 2567 report cites F689 (severity J), on accident hazards and supervision, and F609 (severity D), on reporting of alleged violations. According to the 2567 report, inspectors called an immediate jeopardy on February 21, 2025. The facility's removal plan included a fall risk audit of all residents, zone monitoring with 15-minute safety rounds, updated care plans and staff training. The immediate jeopardy was removed on February 25, 2025.

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According to the 2567 report, Resident 1 was a woman with dementia, kyphosis (an abnormally curved spine) and a history of falls, assessed as high risk for falls. A physician's order called for a wheelchair with a self-release belt, a device meant to remind a resident to call for help before getting up. Inspectors found she had already fallen in April 2024 and again in June 2024, when she leaned forward with the belt on and fell face down, getting a large bump on her forehead. The incident reviews recommended frequent checks, but inspectors found no record that the belt was examined for wear.

Inspectors found that on November 15, 2024, while Nursing Assistant 1 was wheeling her to the dining room, Resident 1 fell face forward out of the wheelchair. She sustained a broken nose and a head contusion (a bruise to the brain) and was hospitalized from November 15 to 16, 2024. CNA 1 told inspectors the Velcro on the belt was worn out and no longer held the straps together, and that the facility ordered new belts after the fall.

The 2567 report cites F689 (severity G), on accident hazards, supervision and assistive devices. Inspectors found the facility failed to keep the belt in working condition, did not develop a care plan for its use, and did not follow its own fall policy, which calls for new or different interventions when falls keep happening.

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According to the citation, CDPH investigated a complaint and a facility-reported incident in August 2024 about a resident whose right hip was swollen, red and bruised. Resident 1 was a woman with dementia and Alzheimer's disease. Her assessment and care plan said she was fully dependent on staff and needed two people to help with transfers between a chair and the bed.

CDPH determined that on August 13, 2024, at about 10 a.m., CNA 1 moved Resident 1 by himself from her geri-chair (a large padded chair) to her bed to change her brief. He told inspectors he heard a popping sound and she became more agitated, but he did not report it to a nurse. He said he knew she needed two-person help but thought that applied more to female CNAs, and that he wanted her ready before her family arrived. Later that morning her family found her in pain with a very swollen thigh. At a general acute care hospital she was found to have a displaced fracture of the lower right femur (thigh bone) broken into several pieces. She had surgery on August 17, 2024, to place a metal rod inside the bone.

Inspectors found the facility failed to make sure staff followed her care plan and its own policies on reporting changes in condition, resident safety and asking for help when lifting. CDPH issued a Class A citation with a $22,500 penalty. The federal 2567 report cites F689 (severity G), on accident hazards, supervision and assistive devices.

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According to the citation, CDPH received a complaint on July 8, 2024, that a resident choked on a meal, and visited the facility on July 10, 2024. Resident 1 was a 72-year-old man with blindness, a seizure disorder and dementia. His code status was Full Code, meaning staff were to attempt all life-saving measures, including CPR (cardiopulmonary resuscitation).

CDPH found that on July 6, 2024, at 5:27 p.m., Resident 1 slumped forward in his wheelchair during dinner in the dining room and stopped responding. Video reviewed by inspectors showed CNA 5 performing the Heimlich maneuver. According to the 2567 report, a licensed vocational nurse told CNA 5 to wheel him back to his room so CPR could be done there. A crash cart arrived at 5:35 p.m. and CPR began, and paramedics arrived at 5:43 p.m. Inspectors found an eight-minute delay in starting CPR and that staff did not call 911 as soon as he was found unresponsive. He was pronounced dead at the facility at 6:03 p.m.

CDPH issued a Class A citation with a $60,000 penalty. The federal 2567 report cites F678 (severity J), on CPR. According to the 2567 report, inspectors called an immediate jeopardy on July 12, 2024. The facility's removal plan included counseling the two staff members, emergency response training, training by an outside basic life support instructor, taking four nurses and CNAs with lapsed CPR cards off the schedule until they were recertified, and monthly mock code drills. The immediate jeopardy was removed on July 16, 2024.

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According to the 2567 report, Resident 1 was a man under a conservatorship (a court-appointed person manages his affairs). In March 2024 he had tried to leave the facility by climbing over a patio fence. Inspectors found that the care plan written after that attempt had no interventions to prevent elopement (leaving without the facility's knowledge), and that two of his elopement risk assessments did not actually assess that risk.

Inspectors found that on June 16, 2024, at 8:49 p.m., Resident 1 opened a door to a patio, staff did not respond to the door alarm, and he climbed over the fence. He left at 8:51 p.m. and, as of July 8, 2024, had not been found. The report states this placed him at risk of exposure to rain or cold, injury from traffic, medical complications from going without his prescribed medications, malnutrition, dehydration and possible death. Inspectors found the facility failed to supervise him on the patio, did not assess him accurately, and did not follow its own elopement risk assessment policy.

The 2567 report cites F689 (severity J), on accident hazards, supervision and assistive devices. Inspectors called an immediate jeopardy on June 21, 2024. According to the report, the facility's removal plan included staff assigned to watch exit zones every shift, hourly location logs for high-risk residents, camera monitors at each nursing station, sound alarms on the doors, mesh around the patio fence, and a quote to make the fence taller. The immediate jeopardy was removed on June 24, 2024.

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