Live Oak Rehabilitation Center in San Gabriel: Inspection Record Review, Complaints and Abuse Reports (Updated October 30, 2026)

CDPH made an unannounced visit on June 18, 2026, to investigate a facility-reported fall. According to the citation, Resident 1 had already fallen on June 4, 2026. CDPH found the facility's fall risk evaluation after that fall did not accurately identify his risk factors, and the facility did not develop a care plan with interventions to prevent another fall, as its own policies required.

CDPH found that on June 9, 2026, CNA 1 left Resident 1 sitting alone in his wheelchair in the hallway, although he had been assessed as needing contact guard assistance (a staff member keeping light, constant hands-on contact for balance) while in the wheelchair. According to the citation, staff did not give him the partial or moderate help he needed when he wheeled himself into his room and tried to move from the wheelchair to his bed around 9 p.m. He had an unwitnessed fall (found on the floor with no one seeing how it happened).

According to the citation, an X-ray at the facility the next day showed a new compression fracture of the T12 vertebra (the last bone of the middle back). He was transferred to a hospital on June 11, stayed five days, and was ordered to wear a TLSO brace (a rigid back brace) for back pain. CDPH issued a Class A citation with a $25,000 penalty that was trebled to $75,000.

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CDPH made an unannounced visit on March 10, 2026, to investigate a facility-reported incident of inappropriate sexual behavior between two residents. According to the citation, on March 7, 2026, Resident 2 was seen in Resident 1's room on top of her, touching her breast while kissing her on the lips. CDPH found the facility failed to protect Resident 1's right to be free from sexual abuse, which the citation defines as sexual contact without the person's permission or with someone who may not be able to consent.

According to the citation, Resident 1 had cerebrovascular disease and a stroke with aphasia (difficulty speaking or understanding language). Her assessment showed moderately impaired decision-making, and she depended on staff for nearly all daily care. Resident 2 could move around in a manual wheelchair and was assessed as cognitively intact.

CDPH also reviewed an earlier record. A change of condition note from December 17, 2025, recorded that Resident 2 tried to kiss Resident 1 on the cheek in the hallway outside her room and was pulled away. According to the citation, after the March incident Resident 2 was placed on one-to-one monitoring and had a psychiatric evaluation, and he denied getting on top of her, saying he only meant to greet her. The citation states the incident could cause her negative emotional and mental effects. CDPH issued a Class A citation with a $25,000 penalty.

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The 2567 report states that around 12:17 p.m. on October 7, 2025, Resident 2 was seen on video surveillance and by a visiting family member pushing Resident 1 down a hallway in her wheelchair and touching, caressing and squeezing her breasts while she repeatedly pushed his hand away. Inspectors found the facility failed to protect Resident 1 from sexual abuse. According to the report, Resident 1 had severely impaired decision-making, and inspectors wrote that a person in her position could feel hopelessness, helplessness and humiliation.

The 2567 report states CDPH called an immediate jeopardy (a situation likely to cause serious harm) on October 9, 2025, in the presence of the director of nursing and the administrator, and the facility provided an acceptable removal plan on October 10. Inspectors wrote that the incident also placed other residents at risk from Resident 2.

The 2567 report states the removal plan included separating the two residents, assessments of Resident 1 by nursing staff, the director of nursing and the social services director, and psychologist and psychiatrist evaluations for both residents. Resident 2 was placed on one-to-one supervision, with weekly psychologist visits to decide when it could end, and staff were to monitor him every shift for triggers. Social services planned daily visits for 72 hours and then weekly visits for eight weeks, and the facility started hallway monitoring. Inspectors cited F600 at severity J for failing to keep a resident free from abuse.

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CDPH made an unannounced visit on August 6, 2025, to investigate a facility-reported fall. According to the citation, Resident 1 was a 95-year-old woman with a past stroke, dementia, a history of repeated falls and severely impaired decision-making. She was rated at high risk for falls and depended on staff for toileting hygiene.

CDPH found that on July 21, 2025, CNA 2 helped Resident 1 onto a shower chair in her bathroom and then left to get something from her bed. Resident 1 said she tried to stand to reach the toilet paper, lost her balance and fell, and she was found sitting on the floor in front of the toilet. According to the citation, the facility also did not update her care plan after a July 16 assessment showed declines in her thinking, mobility and daily functioning, and on August 6 her wheelchair sensor pad alarm was not placed correctly under her.

According to the citation, she reported left inner thigh pain of 7 out of 10, and an X-ray showed an intertrochanteric fracture (a break in the upper thigh bone near the hip). She was sent to a hospital, had surgery on July 25 to fix the hip with hardware, and stayed seven days. CDPH issued a Class A citation with a $25,000 penalty trebled to $75,000. The federal 2567 report cited F689 at severity G for failing to give her adequate supervision and help while toileting.

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CDPH made an unannounced visit on April 15, 2025, to investigate a facility-reported allegation that a staff member "smacked" Resident 1's back on April 10, 2025. According to the citation, Resident 1 was a 78-year-old woman with dementia, and her assessment showed severely impaired decision-making. CNA 1 had been assigned to watch her one-to-one.

CDPH found that around 4:42 p.m. on April 10, as Resident 1 stood up from a chair at a nurses' station and walked toward the desk, CNA 1 grabbed the back of her shirt, which pulled the shirt against the front of her neck. Resident 1 turned and threw a cup of water in CNA 1's face, and CNA 1 slapped her back with the left hand, making a loud smacking sound. According to the citation, two other nursing assistants saw it, and surveillance video reviewed with the administrator showed the same sequence. The administrator told inspectors he also saw it from his office door and that CNA 1 did not follow the facility's abuse policy.

CDPH determined the facility failed to protect Resident 1 from physical abuse and corporal punishment, did not treat her with respect and dignity, and did not follow its own policies. According to the citation, this could affect her emotional, mental and psychosocial well-being. CDPH issued a Class A citation with a $25,000 penalty.

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CDPH made an unannounced visit on February 15, 2023, to investigate a complaint about a death and quality of care. According to the citation, Patient 1 was an 88-year-old woman with congestive heart failure and end stage kidney failure who needed dialysis. Her POLST (a medical order for emergencies) called for CPR and full treatment. A nurse last saw her responsive at 3:30 a.m. on February 11, 2023, and found her unresponsive at 5:30 a.m. and called a code blue.

CDPH found that staff did not place her flat on her back on a firm surface during CPR. LVN 2 told inspectors her bed was stuck with the head raised, staff did not use a CPR board, and the mattress was not hard. The director of nursing told inspectors CPR is ineffective if the patient is not flat on a hard surface. According to the citation, LVN 1 and CNA 1 also did not keep CPR going without interruption until paramedics took over, and the emergency cart checklist had not been completed from February 1 to February 15.

According to the citation, Patient 1 died at 5:40 a.m., and the failures placed the facility's 65 full code patients at risk. CDPH issued a Class A citation with a $25,000 penalty; the facility appealed, and the final penalty was $17,500. The 2567 report cited F678 at severity K and states an immediate jeopardy was called on February 15 and removed on February 17 after the facility's plan, which included CPR recertification for nursing and therapy staff, hands-on training on positioning during CPR, and emergency cart checks every shift.

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