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

According to the citation, CDPH made an unannounced visit on June 23, 2025 to investigate a complaint about resident abuse. Resident 1 was a 68-year-old man with dementia and Alzheimer's disease who used a wheelchair. CDPH found the facility did not ensure he was free from physical and verbal abuse by the facility's security guard.

The citation states that around 9:40 PM on June 19, 2025, Resident 1 came to the nursing station yelling after staff redirected him away from the women's hall. CNA 1 saw the security guard argue with Resident 1 and hit him on the back of the head with an open hand. According to a police report reviewed by CDPH, Resident 1 told officers he had been slapped and cursed at, and the guard left before police arrived. The facility notified the physician and police, and progress notes state the guard was not allowed to return. The next day Resident 1 said his head hurt and asked for pain medicine, and he was sent to a hospital for evaluation. The department found he had pain in his head, said he felt embarrassed, and needed the hospital transfer.

CDPH issued a Class A citation in the Patient Rights category with a $25,000 penalty. The federal 2567 report from the same investigation cites F600 (free from abuse and neglect) at severity G.

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According to the 2567 report, inspectors found the facility did not protect Resident 5 and Resident 35 from abuse by another resident, Resident 206. Resident 206's care plan called for watching for signs of coming violence and keeping her away from others when those signs appeared. Nursing notes showed staff were monitoring her for aggressive behavior in early June 2024.

The report states that on June 3, 2024, Resident 206 became angry and splashed coffee on Resident 35, who had dementia. Inspectors found that a social services note documenting the coffee incident was later struck out by the social services director and marked as incorrect documentation. On June 23, 2024, around 2 PM, Resident 206 hit her roommate, Resident 5, in the face with an open hand as Resident 5 tried to walk out of their room. Notes state Resident 5 was struck three times. Police arrived and arrested Resident 206, and the report states Resident 5 asked police to take Resident 206 away. Inspectors found both residents suffered psychosocial (mental and emotional) harm.

The 2567 report cites F600 (free from abuse and neglect) at severity G and F609 (reporting of alleged violations) at severity D.

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According to the 2567 report, Resident 1 had dementia and pulmonary histoplasmosis (a fungal infection of the lungs). On March 19, 2024, the facility received an order from a hospital infectious disease physician for itraconazole (an antifungal medication) 200 mg by mouth three times a day for three days, then twice a day with no end date. Inspectors found the facility gave the three-day doses but did not enter or carry out the twice-daily order. The report states Resident 1 did not receive itraconazole from March 23 to April 24, 2024. LVN 2 told inspectors she could not find the twice-daily order.

The 2567 report states that at a lung clinic visit on April 25, 2024, a scan showed the infection had gotten worse, and the pulmonologist sent Resident 1 to a hospital. A blood test there showed almost no itraconazole in his system. A bone marrow biopsy found the infection had spread to his bones, and the infectious disease physician wrote that not receiving the medication at the facility was almost certainly the reason the disease progressed. He stayed in the hospital for 20 days, until May 14, 2024, and was treated with several antifungal drugs, including one given by IV.

Inspectors cited F684 (quality of care) at severity G.

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According to the 2567 report, Resident 5 had dementia, could not understand and make decisions, had a history of elopement (leaving without staff knowledge), and was at risk for wandering. Inspectors found the facility did not develop a care plan that set how often staff should check his location, did not review his elopement assessment for accuracy, and did not update his care plan to require checks every 15 minutes, as an earlier Immediate Jeopardy removal plan approved on February 29, 2024 required. Inspectors also found the facility did not have enough staff on the 11 PM to 7 AM shift on March 16, 2024.

The report states that around 5:15 AM on March 16, 2024, staff found Resident 5 had eloped, and he remained missing. Inspectors found he faced an increased risk of serious harm or death from missing his antipsychotic medications and physical therapy.

The deficiency was cited under F689 (accident hazards, supervision and devices) at severity J. According to the report, inspectors called an Immediate Jeopardy on March 20, 2024, and removed it on March 22 after verifying the facility's removal plan. The plan included searching hospitals, shelters and clinics for Resident 5, reassessing 51 residents and placing 16 at-risk residents on visual checks every 15 minutes, assigning a staff member to watch the front door on every shift, daily checks of the exit doors, staff training, a binder with photos of at-risk residents, and weekly team reviews for six months.

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According to the 2567 report, Resident 4 was admitted on February 9, 2024 after eloping twice from another facility within 24 hours, and the facility assessed her as at risk for elopement. Inspectors found that on February 11, 2024, staff called 911 when she threw her body and hands against the front glass door trying to leave, but the interdisciplinary team meeting the next day did not address that attempt or her earlier elopements. The facility also did not provide adequate supervision or strict hourly checks. The report states she eloped on February 22, 2024 between 6:30 and 7 PM and had not been found as of February 29.

Inspectors called an Immediate Jeopardy on February 26, 2024 and removed it on February 29 after verifying the facility's removal plan. The report states the plan included staff training, screwing a bathroom window shut, replacing a wooden fence, grouping 18 at-risk residents in designated rooms, and staff checks every 15 minutes.

The 2567 report also states that on January 28, 2024, Resident 2, who was known to be aggressive and had refused several doses of her medications, slapped Resident 1 in the face on the patio. Inspectors found Resident 2 was not monitored as her care plan required. The findings were cited under F689 (accident hazards, supervision and devices) at severity J and F600 (free from abuse and neglect) at severity G.

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According to the citation, CDPH made an unannounced visit on July 13, 2023 to investigate the elopement of Resident 1. He had epilepsy and dementia, was severely cognitively impaired, wandered, and had been assessed as at high risk for elopement (leaving without staff knowledge). CDPH found the facility did not evaluate his elopement risk when staff saw him regularly sitting by the front door, did not check whether his care plan was working or change it, and did not document routine checks of his location as its own policy required.

The citation states Resident 1 was last seen around 5:45 AM on July 7, 2023 and was missing at the 6 AM medication pass. The administrator told CDPH staff thought he was on the patio near a gate that staff use to enter and leave, and he could have exited without staff knowing. According to the citation, paramedics found Resident 1 unconscious on the ground in a pool of blood, and he was admitted to a hospital intensive care unit on July 12, five days after he left. LVN 2 said he had bruises on his face. The administrator also told CDPH his elopement care plan had not been reviewed quarterly and no team meeting had updated his risks.

CDPH issued a Class A citation with a $20,000 penalty. The federal 2567 report cites F689 (accident hazards, supervision and devices) at severity G.

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