Hyde Park Healthcare Center in Los Angeles: Inspection Record Review, Complaints and Abuse Reports (Updated October 30, 2026)

CDPH made an unannounced visit on January 21, 2026, to investigate a facility-reported incident of resident-to-resident abuse that happened on January 17, 2026. According to the citation, Resident 1 was a 50-year-old woman with spastic quadriplegic cerebral palsy (stiffness and limited movement in all four limbs). She had severe cognitive impairment, was under a court conservatorship, and staff described her as "childlike."

CDPH found that Resident 2 had a documented history of sexually disinhibited and boundary-violating behavior during a recent hospital stay. According to the citation, the hospital's behavioral precautions were discontinued when he was admitted to the facility, and the facility did not identify or assess his known behavior, did not put a behavioral care plan in place, and did not follow its own abuse prohibition policy.

According to the citation, on January 17, 2026, Resident 2 sexually assaulted Resident 1. Her roommate ran out of the room asking for help, and staff found Resident 2 on top of Resident 1. She was sent to an acute care hospital, where a sexual assault examination found bruising to her genital area, and she received preventive treatment for sexually transmitted infections and emergency contraception. CDPH issued a Class A citation with a $25,000 penalty. In the related federal survey, inspectors cited F600 at severity G.

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CDPH received a facility-reported incident on November 3, 2025, saying a resident had been hit by his roommate, and made an unannounced visit on November 4. According to the citation, Resident 1 was a 78-year-old man with Parkinson's disease, dementia, diabetes and encephalopathy (a condition that affects brain function). His cognitive skills were severely impaired. Resident 2, his roommate, was 51 years old.

CDPH found the facility failed to carry out its abuse and neglect policy, which says each resident has the right to be free from abuse, when Resident 2 physically assaulted Resident 1. According to the citation, Resident 1's care plan called for staff to watch for factors that could lead to violent behavior.

According to the citation, on November 2, 2025, at 8:56 a.m., Resident 1 was found with discoloration, cuts and bleeding on the top of his head, his right ear and the right side of his face after the attack. He was sent to an acute care hospital, where staff found a 1-centimeter cut above his right eye and a shallow cut on the back of his scalp. Scans of his head and face showed no acute findings. He declined wound care and repair of the cuts, was admitted to the hospital, and returned to the facility on November 4, 2025. CDPH issued a Class A citation with a $15,000 penalty.

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The 2567 report states that inspectors found the facility failed to make sure Resident 1 was free from physical abuse when another resident, Resident 2, pushed her to the floor on November 30, 2025. Resident 1 had diabetes and moderately impaired thinking skills. Resident 2 had Alzheimer's disease and Parkinson's disease, and her records described physical aggression toward her peers that day.

According to the 2567 report, at 11:53 p.m. the charge nurse saw Resident 2 walk up to Resident 1 and push her to the floor. Resident 1 hit the back of her head and was bleeding. The charge nurse held a towel to the wound and called 911. At an acute care hospital, Resident 1 was treated for minor head trauma and a 1-inch cut on the back of the scalp, which was closed with two staples, and she returned to the facility on December 1, 2025.

Inspectors found in interviews that Resident 1 was talking with another resident in the hallway when Resident 2 pushed her; Resident 1 told them it happened for no reason. That other resident told inspectors she saw the push and saw Resident 1's head bleeding. The 2567 report states the facility's abuse policy said a resident who attacks another resident would be removed from the setting. The deficiency was cited as F600 at severity G.

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CDPH made an unannounced visit on October 8, 2025, to investigate an allegation of a resident elopement (leaving the facility without supervision or permission). According to the citation, Resident 1 was a 46-year-old man with moderate cognitive impairment. He spent a lot of time walking around the facility, had a very short attention span and was hard to redirect. His September 12, 2025, elopement risk assessment rated him as not an elopement risk and did not address his cognition or history of elopement.

According to the citation, on September 24, 2025, staff saw Resident 1 fill a cup from a wall-mounted hand sanitizer dispenser and try to drink it. His physician strongly recommended a 5150 hold (a short involuntary hold for psychiatric evaluation) to protect his safety, and his care plan called for hourly checks. CDPH found the facility did not include his cognition and poor judgment in his elopement risk assessment, did not reassess his risk after this change of condition, did not follow its elopement policy, and did not follow the physician's recommendation for the 5150 hold.

The citation states Resident 1 was last seen at 1:40 a.m. on September 25, 2025, and at 2:40 a.m. a licensed vocational nurse found he was gone. He was found 35 days later, on October 30, 2025, sleeping on a bench. CDPH issued a Class A citation with a $20,000 penalty trebled to $60,000. The related federal survey cited F689 at severity J.

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CDPH made an unannounced visit on February 27, 2025, to investigate a complaint about a resident fall. According to the citation, Resident 1 was a 65-year-old man with paraplegia (paralysis of the lower body) and muscle wasting. His assessment showed he was totally dependent on staff and needed two people to help him transfer. His physical therapy plan called for transfers with a Hoyer lift, a mechanical lift used to move residents between a bed and a chair.

CDPH found the facility did not provide adequate supervision, did not carry out Resident 1's care plan, and did not follow its mechanical lift policy or the lift manual's recommendation to use two people for transfers. According to the citation, on February 15, 2025, CNA 1 moved Resident 1 from the bed toward a geri-chair (a padded reclining chair) with the Hoyer lift and no second staff member. Resident 1 told inspectors the lift battery died, CNA 1 lowered him back to bed to get batteries, and when CNA 1 tried again he fell to the floor on his knees. A licensed vocational nurse told inspectors he was always supposed to be transferred with the lift and two people.

The citation states Resident 1 had knee pain rated 7 to 8 out of 10 and a small skin tear. On February 20, 2025, he was sent to an acute care hospital, where X-rays showed an acute fracture of the right femoral neck (the part of the thigh bone just below the hip). CDPH issued a Class A citation with a $25,000 penalty, and the related federal survey cited F689 at severity G.

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According to the citation, during a recertification survey on July 18, 2023, CDPH observed Resident 17 looking frightened as Resident 8 forcefully pushed her wheelchair toward his room. On July 20, 2023, CDPH received a complaint that on June 17, 2023, Resident 63 had been sexually abused by Resident 8, who was found climbing into her bed. Resident 8 was a 52-year-old man. Resident 63 was a 77-year-old woman.

CDPH found the facility failed to keep Resident 63 and Resident 17 free from physical and sexual abuse by Resident 8. According to the citation, he climbed on top of Resident 63, pushed Resident 17 into a room and slammed the door behind him while she screamed for him to stop, and tried to put his hand into adult briefs. CDPH found the facility also did not follow its abuse prevention policy after the first incident and did not assess, care plan or monitor Resident 8's sexual impulses and his physical behavior toward other residents.

According to the citation, on June 17, 2023, CNA 3 walked into Resident 63's room and saw Resident 8 with his hand on her adult brief. He was sent to an acute care hospital for evaluation and readmitted on June 26, 2023. Resident 17 said Resident 8 touched her inappropriately on July 18, 2023. CDPH issued a Class A citation with a $25,000 penalty, and the related federal survey cited F600 at severity G.

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CDPH made an unannounced visit for an annual recertification survey on February 9, 2023. According to the citation, licensed nurses documented on the Medication Administration Records (MARs) of Residents 4 and 23 that they received nutrition supplements ordered by their physicians and recommended by the dietitian, when the supplements were not provided. Resident 4 was a 61-year-old woman with severe protein-calorie malnutrition (not getting enough protein and calories). Resident 23 was a 91-year-old man with protein-calorie malnutrition and dysphagia (trouble swallowing).

CDPH found that nurses charted House Protein Nutrition (a liquid supplement) for Resident 4 in January and February 2023, although the kitchen had no order for it and was not serving it. According to the citation, her weight dropped from 115 to 93 pounds between January 6 and February 3, 2023. LVN 2 told inspectors she signed the MAR showing the supplement was given without checking whether it was served. For Resident 23, nurses charted Glucerna (a meal-replacement shake) for December 2022 through February 2023 when there was no Glucerna in the facility, and he lost 8 pounds in 29 days.

The department determined the facility failed to ensure licensed nurses did not falsify these records, and cited it under the state law on falsification of health records. According to the citation, the MARs did not accurately reflect what the two residents ate and put them at risk for poor nutrition, severe weight loss and inaccurate treatment evaluations. CDPH issued a Class A citation with a $25,000 penalty.

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CDPH made an unannounced visit for an annual recertification survey on February 9, 2023. According to the citation, Resident 4 was a 61-year-old woman with severe protein-calorie malnutrition (not getting enough protein and calories) and a stage two pressure ulcer (an open bed sore). Her physician ordered 4 ounces of House Protein Nutrition, a liquid supplement, three times a day with meals. Resident 23 was a 91-year-old man with protein-calorie malnutrition and dysphagia (trouble swallowing) who had a physician order for Glucerna, a meal-replacement shake.

CDPH found the facility failed to make sure Resident 4 received her protein supplement with meals, failed to complete a comprehensive nutritional assessment for her as its policy required, and failed to make sure Resident 23 received his ordered Glucerna and protein supplement. Inspectors found no supplement on Resident 4's lunch tray on two days in February 2023, and CNA 4 told inspectors he was not aware she was supposed to have one and always fed her without it.

According to the citation, Resident 4 lost 22 pounds, or 19% of her usual weight, between January 6 and February 3, 2023. Resident 23 lost 8 pounds, or 6.8% of his usual weight, between December 6, 2022, and January 3, 2023. CDPH determined this placed both residents, who already had impaired nutrition, at risk of further decline. CDPH issued a Class A citation with a $25,000 penalty, and the related federal survey cited F692 at severity G.

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