University Park 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 July 1, 2026 to investigate a facility-reported incident of resident abuse. CDPH found that on June 15, 2026, Resident 2 called Resident 3 names, threatened to beat him up and spat on him. Resident 2 was to be on 72 hours of staff monitoring, and the facility moved him into the room of Resident 1, a bedbound 65-year-old man with muscle weakness and muscle wasting, to "avoid future issues."

Inspectors found that on June 18, 2026, at 8:45 a.m., Resident 2 hit Resident 1 on the head with an overbed table. Staff heard a scream from the room, and Resident 1 was bleeding from a cut on the left side of his head. The facility called 911, and at an acute care hospital he was diagnosed with blunt trauma, a closed head injury and a scalp laceration that was closed with two staples. According to the citation, police took Resident 2 from the facility that morning.

The department determined the facility failed to protect Resident 1 and Resident 3 from abuse, did not follow its abuse prevention and resident-to-resident altercation policies, did not investigate the June 15 incident, and did not make sure nurses stepped in when Resident 2 became agitated. CDPH found the director of nursing, an administrator and LVN 1 did not report it on time to the ombudsman, CDPH and police. CDPH issued a Class A citation with a $25,000 penalty. The federal 2567 report cites F600 (free from abuse and neglect) at severity G, F607 (abuse and neglect policies) at severity E and F609 (reporting of alleged violations) at severity D.

↑ Back to this finding in the timeline

According to the citation, CDPH made an unannounced recertification survey visit on February 10, 2025. CDPH found that Resident 77, an 84-year-old man admitted in late January with pneumonia, chronic obstructive pulmonary disease (a long-term lung disease), a bloodstream infection and dysphagia (difficulty swallowing), did not receive care that met professional standards. He had a physician's order for oxygen as needed for shortness of breath, but the facility did not include it in his assessment or any care plan.

Inspectors found staff did not carry out the mouth and throat exercises in his speech therapy care plan for aspiration risk, or the deep-breathing exercises with an incentive spirometer in his respiratory care plan. CDPH found that LVN 4 recorded inaccurate vital signs on three dates and that staff did not do the routine checks required each 8-hour shift. The last skilled nursing assessment was documented at 1:45 p.m. on February 11. At 7:32 a.m. the next morning, LVN 3 found him unresponsive in his room. Staff began CPR and called emergency services, and paramedics pronounced him dead at 8:08 a.m.

The 2567 report states that in the same survey, the facility also failed to protect two residents from physical abuse by another resident, who hit each of them in February 2025. That finding is cited as F600 (free from abuse and neglect) at severity G. The report also cites F684 (quality of care) and F688 (increase or prevent decrease in range of motion and mobility) at severity G; the full narrative is in the linked report. CDPH's record lists the citation as Class A with a final penalty of $50,100, down from $100,000 first assessed.

↑ Back to this finding in the timeline

The 2567 report states that on September 4, 2024, the day he was admitted, Resident 1, a man with dementia, was left unattended while lying and crawling on the floor of a facility hallway for about 59 minutes. His care plan for crawling out of bed called for constant supervision. Inspectors found that nine staff members, including CNAs, licensed vocational nurses and a registered nurse supervisor, watched and allowed him to crawl and lie on the floor with his body partly uncovered, without giving him help, comfort or safety.

CDPH found from the facility's surveillance video that, starting at about 10 p.m., Resident 1 crawled out of his room and lay belly down on the hallway floor near the nurses' station. His gown was dragging on the floor, his upper body was exposed and his incontinence brief was around his knees. Staff were seen talking at the nurses' station, working at a medication cart and walking past him with linens while he tried to get up and curled into a fetal position. At one point another resident using a walker stepped over him. CNA 1 told inspectors that at 2:30 a.m., during rounds, she found Resident 1 unresponsive and called a nurse.

Inspectors found the facility failed to protect Resident 1's right to be free from neglect. The report states that, under the reasonable person concept, a person with his level of impaired cognition who is subjected to neglect may have lifelong psychological effects, including embarrassment and humiliation. The 2567 report cites F600 (free from abuse and neglect) at severity G.

↑ Back to this finding in the timeline

The 2567 report states the facility failed to give Resident 1, a man with schizophrenia (a serious mental illness that affects thinking, feelings and behavior) and a history of wandering, the behavioral health care called for in his assessment. Inspectors found staff did not monitor his schizophrenic behavior each shift as the physician ordered, did not evaluate or update his care plan interventions as his behavior and needs changed, did not develop a care plan for his wandering that set how often he should be supervised, and did not step in when he became agitated before it escalated, as his care plan directed. His assessment showed his behavior, care rejection or wandering had gotten worse since a prior assessment.

CDPH found that on June 14, 2024, Resident 1 wandered into Resident 2's room and, after being told to leave, hit Resident 2 in the face, and Resident 2's lip bled. Facility records noted that Resident 2 fell and had a cut of less than one centimeter on his upper lip. A CNA told inspectors she heard a commotion, saw Resident 1 swinging his arms and striking Resident 2, and tried to separate them. Resident 1 was sent to an emergency room for a psychiatric evaluation. When inspectors spoke with Resident 2 weeks later, he had no visible injury and said he believed Resident 1 did not mean to hit him.

Inspectors found that these failures meant Resident 1 did not receive the behavioral health services he needed. The 2567 report cites F740 (behavioral health services) at severity G.

↑ Back to this finding in the timeline

According to the citation, CDPH made an unannounced visit on January 22, 2024 for a recertification survey. CDPH found that Resident 66, a woman with Huntington's disease (an inherited brain disease), had a history of multiple falls, an unsteady gait and impulsive behavior, and needed supervision or hands-on help when walking and transferring. A July 2023 form noted that she refused a helmet and wheelchair offered as fall precautions.

Inspectors found the facility did not give her the correct level of help with transfers and walking on July 19, August 18 and September 20, 2023, did not revise her fall care plan with specific interventions and levels of assistance, and did not complete a fall risk assessment after each fall. Her care plan had no interventions for walking, and staff told inspectors it was last updated on July 31, 2023, although it should have been updated after the August and September falls. According to the citation, on December 8, 2023, she had an unwitnessed fall in her room and hit the back of her head. At an acute care hospital she was treated for a one-inch cut closed with staples and a hematoma (a pool of blood under the skin) on the back of her head, along with skin tears on her abdomen and back.

According to the citation, CDPH issued a Class A citation with a $25,000 penalty that was trebled to $75,000. The 2567 report from the same survey cites F689 (free of accident hazards, supervision and devices) at severity G, along with F609 (reporting of alleged violations) at severity D and F880 (infection prevention and control) at severity L. The full narrative for F609 and F880 is in the linked report.

↑ Back to this finding in the timeline

According to the citation, CDPH made an unannounced visit on July 19, 2023 to investigate a facility-reported incident about Resident 1 eloping, meaning leaving the facility without telling anyone. CDPH found that Resident 1, a woman admitted on July 13, 2023, had shown wandering behavior and had said she was afraid inside the facility. On July 15 she was found outside in the smoking area, said she did not feel safe inside, and refused to go back to her room all night. She refused a prescribed medication the next day.

The department determined the facility did not provide adequate supervision, did not follow its wandering and elopement policy by adding safety strategies and interventions to her care plan, and did not start an interdisciplinary team review when she said she felt unsafe and showed paranoia. CDPH found the facility also did not notify a physician that she was missing; the facility's physician told inspectors he was not aware she was gone. On July 18, 2023, a nurse was told around 3:30 p.m. that she was on the smoking patio, and after a phone call came for her at about 4:50 p.m., staff could not find her. Staff searched the facility and called police to file a missing person report. According to the citation, she had not been found. The administrator told inspectors the facility did not start any of the care plan interventions its policies required.

According to the citation, CDPH issued a Class A citation with a $25,000 penalty, and the state's record lists the final amount as $22,500. The federal 2567 report cites F689 (free of accident hazards, supervision and devices) at severity G.

↑ Back to this finding in the timeline

The 2567 report states the facility failed to ensure Resident 2 was free from physical abuse when Resident 1, who had a history of physical aggression, hit Resident 2 on the left eye on February 7, 2023. Resident 2 had a bruise under and around her left eye. Inspectors found that staff were to monitor Resident 1 every shift for physical aggression. Her care plans called for staff to identify triggers and intervene before her agitation escalated.

Inspectors found the medication administration record showed Resident 1 did not receive two of her ordered medications, including one ordered for aggressive behavior, on February 6 and 7, 2023. According to the report, a licensed vocational nurse noted bruising on Resident 2's left cheek at about 6:30 p.m. on February 7. Resident 2 said Resident 1 hit her after Resident 2 used a racial slur toward Resident 1. Resident 2 denied pain and refused an ice pack.

CDPH found the facility did not protect Resident 2 from physical abuse by another resident. The 2567 report cites F600 (free from abuse and neglect) at severity G and F609 (reporting of alleged violations) at severity D. The full narrative on the reporting finding is in the linked report.

↑ Back to this finding in the timeline