Imperial Care Center in Studio City: Inspection Record Review, Complaints and Abuse Reports (Updated October 30, 2026)

CDPH investigated a facility-reported fall during an unannounced visit on April 9, 2026. According to the citation, Resident 1 was a 102-year-old woman with dementia and difficulty walking. She had been identified as a high fall risk and had fallen in the facility on February 4 and February 8, 2026. Her care plan called for a front-wheel walker, encouragement to use a wheelchair, frequent visual monitoring and an assistive device. Her assessment showed she needed supervision or touching assistance from staff to walk.

CDPH found that the facility did not place Resident 1 in its Falling Star Program (a system that marks residents at high risk for falls) after the two February falls, as its own policy required. Inspectors found staff also did not provide the front-wheel walker that the care plan and the physical therapist recommended, did not follow the care plan's wheelchair and monitoring steps, and did not give her the walking supervision her assessment called for.

According to the citation, on March 30, 2026, at 1:45 p.m., Resident 1 fell in a hallway while walking without staff supervision and without a walker or wheelchair. She had bleeding from the bridge of the nose, a scalp laceration (a cut), a forehead hematoma (clotted blood under the skin) and facial swelling. She was later diagnosed with a nasal fracture and blunt head trauma. CDPH issued a Class A citation with a $25,000 penalty.

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The 2567 report states that Resident 1 was cognitively impaired and had been admitted to a secured facility with locked doors. Inspectors found that on April 24, 2025, at 6:48 p.m., RNA 1, a restorative nurse aide, opened the facility's locked gate without checking Resident 1's identity because RNA 1 thought Resident 1 was a visitor. Resident 1 then left the building.

Inspectors found the facility failed to provide supervision and to prevent the elopement (leaving without supervision or permission). The 2567 report states this placed Resident 1 at risk of a traffic accident on a busy street, of missing medications, and of exposure to heat and cold that could lead to serious injury, harm or death. The next day, a registered nurse, a licensed vocational nurse and two police officers found Resident 1 at the resident's apartment about 7.8 miles away and brought the resident back. Staff noted a scab on the left knee, and Resident 1 was sent to an acute care hospital for evaluation that evening.

The 2567 report states the state survey agency called an Immediate Jeopardy on April 26, 2025, and the deficiency was cited as F689 at severity J. The facility's accepted removal plan included suspending RNA 1 pending investigation, training staff on supervision, elopement and resident identification, checking that residents wore ID wristbands, photographing residents for their records, and assigning staff to watch the reception area. Inspectors found the plan in place and removed the Immediate Jeopardy on April 27, 2025.

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The 2567 report states that on May 1, 2024, at 5:30 p.m., a student nurse walked into Resident 1's room and saw CNA 1, a certified nursing assistant, slapping and punching Resident 1 on the arms and back. Resident 1 had dementia and severely impaired cognition. Inspectors found the facility did not follow its own abuse prevention policies, did not make sure CNA 1 had received abuse training, and did not protect Resident 1 from physical abuse by CNA 1.

Because of Resident 1's cognitive impairment, inspectors applied the reasonable person concept and found that a person subjected to this kind of abuse could feel hopelessness, helplessness and humiliation. The 2567 report states the state survey agency called an Immediate Jeopardy on May 9, 2024, and cited F600 at severity J.

According to the 2567 report, the facility's accepted removal plan included a head-to-toe assessment of Resident 1, which found no signs of physical trauma, and visits from a psychiatrist and a psychologist. A family member was notified, and CNA 1 was terminated on May 9, 2024. The plan also listed abuse prevention training for all 150 staff members, interviews with all 117 residents with no new reports of abuse, a review of employee files for abuse training, and daily room rounds by department managers. Inspectors found the plan in place and removed the Immediate Jeopardy on May 10, 2024.

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CDPH made an unannounced visit on February 8, 2024, to investigate a facility-reported incident about abuse and quality of care. According to the citation, Resident 1 was a 53-year-old woman with dementia who was confused, at high risk for falls and had wandering behavior. CDPH found the facility did not give her supervision, redirection and monitoring, did not follow its policies on wandering, falls, supervision and abuse prevention, and did not protect her from physical abuse by another resident, Resident 2.

According to the citation, on February 1, 2024, at 5:10 p.m., Resident 1 tried to enter Resident 2's room and Resident 2 pushed her out. She fell backward onto the hallway floor and hit the back of her head. At an acute care hospital she was diagnosed with blunt head trauma and an acute on chronic subdural hematoma (bleeding between the brain and its covering). Resident 2's care plan listed aggressive behavior, and his records show he later said he pushed another resident. The director of nursing told inspectors the facility reported the injury as an unwitnessed fall and not as resident-to-resident abuse, because its own investigation found it was not abuse.

CDPH issued a Class A citation with a $25,000 penalty that was trebled to $75,000. In the related federal survey, inspectors found the facility failed to protect several residents from neglect and physical abuse, including this incident, and cited F600 at severity K.

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During an unannounced visit on February 8, 2024, CDPH investigated a facility-reported incident about abuse and quality of care. According to the citation, Resident 8 was a 95-year-old woman with dementia and a history of falls. Her care plans called for monitoring at frequent intervals, redirection, help with transfers and walking, and supervision while she walked.

CDPH determined the facility failed to give Resident 8 supervision, redirection and monitoring of her whereabouts, did not follow its policies on wandering, falls, accident prevention and supervision, and did not identify interventions aimed at her specific risks. According to the citation, Resident 8 fell 11 times in the facility between October 2, 2020, and February 9, 2024. After the 11th fall, on February 9, 2024, she was sent to an acute care hospital and diagnosed with a cut near her right eyebrow, small areas of subarachnoid hemorrhage (bleeding between the brain and the tissue that covers it), a possible small subdural hemorrhage and a scalp hematoma.

CDPH issued a Class A citation with a $25,000 penalty trebled to $75,000. In the related federal survey, inspectors cited F689 and F600, both at severity K. The 2567 report states the state survey agency called an Immediate Jeopardy on March 18, 2024. The facility's removal plan included staff training on supervision, assigned hallway monitors, and a revised care plan for Resident 8 that placed her closer to the nurses' station and added a low bed and a floor mat. The Immediate Jeopardy was removed on March 20, 2024.

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CDPH made an unannounced visit on March 21, 2024, to investigate a complaint about quality of care. According to the citation, Resident 1 was a 76-year-old man with diabetes, urinary retention and an indwelling urinary catheter (a tube placed in the bladder to drain urine). He could not understand or make decisions. On February 29, 2024, he pulled out his catheter and had blood in his urine. His care plan then called for watching for signs of urinary tract infection (UTI) and checking his urine for cloudiness, odor, blood and amount.

CDPH found the facility failed to accurately and continuously monitor Resident 1 for signs of UTI, and failed to monitor and document his urine so an infection could be caught and treated. According to the citation, intake and output records described his urine as yellow and clear through March 3, 2024, and there was no intake and output record for March 4.

According to the citation, on the evening of March 4, 2024, a family member found Resident 1 leaning sharply forward. His heart rate was 145 and his blood sugar was 401. Paramedics found his catheter tubing dark brown, murky and apparently clogged. At an acute care hospital he had a fever of 104 degrees and was diagnosed with severe sepsis (a life-threatening reaction to infection) and a UTI. CDPH issued a Class A citation with a $25,000 penalty trebled to $75,000, and the related federal survey cited F690 at severity G.

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CDPH made an unannounced visit on December 12, 2023, to investigate a facility-reported incident about quality of care. According to the citation, Resident 4 had dementia, osteoarthritis and vertigo (dizziness), had severely impaired cognition and was assessed as a high fall risk. A physical therapy discharge summary said she needed stand-by assistance (a staff member close by in case she lost her balance) when walking, and her care plan called for frequent observation.

CDPH found the facility did not give Resident 4 the assistance and supervision called for in her assessment and care plan. Inspectors found the facility also had no policy or protocol saying how often nursing staff should check on residents at risk of falling and wandering in the hallways.

According to the citation, on November 27, 2023, at 8:30 p.m., Resident 4 fell in the hallway in front of her wheelchair. At an acute care hospital she was diagnosed with a head injury, a cut on the forehead and a left shoulder dislocation. Inspectors reviewed surveillance video with the administrator and saw that at 8:28 p.m. nursing staff were inside the nursing station and only residents were in the hallway. CNA 2, who was assigned to Resident 4, told inspectors that she and other aides were in residents' rooms and no nursing staff were in the hallway. CDPH issued a Class A citation with a $20,000 penalty trebled to $60,000. The related federal survey cited F689 at severity G.

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The 2567 report states that on November 8, 2023, at 6:45 p.m., Resident 2 went into Resident 1's room while Resident 1 was lying in bed and punched him several times on the face and body. Inspectors found the facility failed to protect Resident 1's right to be free from physical abuse. Resident 1 had dementia, anxiety and depression, and his assessment showed his thinking skills were intact. Resident 2 had Alzheimer's disease and severely impaired cognition.

According to the 2567 report, CNA 1 heard yelling from the room, found Resident 2 punching Resident 1 while Resident 1 tried to block the blows, and separated the two. A licensed vocational nurse found Resident 1 tense, with redness around the right eye, and records show he was given Tylenol. The 2567 report states Resident 1 told inspectors he had asked Resident 2 to leave his room and Resident 2 began hitting him without giving him a chance to stand up or defend himself. Resident 2's records describe him as confused and aggressive, and he did not remember the incident.

Inspectors found the incident caused Resident 1 pain and anxiety and placed him at high risk of increased depression because of his diagnoses. A social services note said he felt nervous at the time and later said he felt better. The deficiency was cited as F600 at severity G.

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CDPH made an unannounced visit on April 12, 2023, to investigate a complaint related to abuse and seclusion. According to the citation, Resident 1 was an 80-year-old woman with Alzheimer's disease and several mental health conditions. She had impaired cognition, a history of falls, and episodes of agitation and getting out of her bed and wheelchair, and she needed assistance and supervision.

According to the citation, on April 12, 2023, at 1:15 a.m., Resident 1 fell out of bed. Staff sat her in her wheelchair and applied a quick release soft belt, a type of restraint. At 1:36 a.m., RN 1, a registered nurse, wheeled her into an empty, dark resident room, moved a linen cart to partly block the door and left without turning on the lights. CDPH found she stayed there until 5:58 a.m., when she wheeled herself out. The department determined she was subjected to involuntary seclusion (being kept apart from others against her will) for 4 hours and 22 minutes and was at risk for anxiety, depression and other psychosocial harm.

CDPH found the facility also failed to treat Resident 1 with dignity and respect, failed to provide behavioral health services such as psychotherapy, counseling and meaningful activities, and failed to carry out her care plans for falls, self-care, communication and behavior. CDPH issued a Class A citation with a $25,000 penalty trebled to $75,000. The related federal survey cited F603 and F740, both at severity G.

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