complaint·March 24, 2026

PG 2 On the allegation, lack of supervision, resulting in resident being sexually abused at the facility LPA conducted interviews, reviewed R1 and R2’s care plan, R1 and R2’s physicians report, and care notes. LPA observed that R1 and R2 were both memory care residents with a diagnosis of dementia. On 8/13/2025 it is alleged that R2 entered R1’s room and sexually assaulted them. LPA interviewed S1 who is the lead for S3 who stated that on 8/13/2025 S3 had led R2 to Dining for breakfast. Approximately 30 minutes later, S3 noticed that R2 was not at dining. S1 states that other facility staff and S3 were still getting residents to dining for breakfast at this time. R2 was discovered in R1’s room during this time. S1 states that they were told that it appeared that R1 and R2 may have engaged in sexual activities. LPA conducted interviews with S2 S4 and S5. All staff stated that they had heard about the interaction between R1 and R2 however, residents have a personal right to engage in sexual activity, unless there is a court appointed conservator. LPA found that R1 and R2 are not conserved. LPA attempted to interview R1 but was unable to due to their dementia diagnosis. R2 was also unavailable to interview. LPA made attempts to contact S3 but was unable to interview S3 as they are not permanent staff. LPA was unable to determine if the interaction between R1 and R2 was consensual therefore, the allegation of lack of supervision resulting in resident being sexually abused at the facility is unsubstantiated. Report Continues on LIC 9099-C PG. 3 On the allegation facility not following reporting requirements LPA reviewed records and unusual incident reports. LPA observed that the facility reported the interaction between R1 and R2 on 8/18/2025 which is within title 22 guidelines of reporting requirements. LPA observed that the incident happened on 8/13/2025 was reported to police, responsible parties, and to licensing therefore the allegation facility not following reporting requirements is unsubstantiated. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . No deficiencies cited. Exit interview conducted and a copy of this report provided.