Complaint·March 18, 2024

Licensing Program Analyst L. Padgett arrived unannounced to deliver amended investigative findings on the above allegation. LPA met with Paul Rocha and explained the purpose of the visit. The Department investigated the complaint alleging: Staff do not prevent inappropriate interactions between residents. During the course of the investigation the Department conducted interviews with staff and witnesses and reviewed resident and facility records, including incident reports, resident care notes, physician’s report pertaining to Residents R1 and R2. The Department determined that staff on duty did not prevent sexually inappropriate non-consensual interactions between the two residents in the Memory Care Unit. Per Department’s investigation: On 10/24/2023, in the Memory Care Unit of the facility resident R1 was found in resident R2’s bedroom; resident R2 had his arm around resident R1’s waist and resident R1 was pushing resident R2 away. Resident R2’s genitalia was exposed out of his brief. On 10/27/2023 in the Memory Care Unit of the facility staff S1 went to check on resident R2 in his bedroom and saw resident R2 sitting on his bed with resident R1 laying across Resident R2’s body. Resident R1’s pants were down to her ankles, briefs pushed to the side and R2’s fingers were inserted in R1’s genitalia. Staff S1 pulled resident R1 away and assisted resident R1 to her bedroom. Staff S1 also advised Memory Care Director (S2), but Staff S2 stated the residents had personal rights to be involved in romantic/physical relationships. Based on resident R1’s Admission Agreement, resident R1 has a power of attorney assigned and is unable to make decisions or give consent. During the Department’s interviews with Executive Director (S3) and Memory Care Director (S2); they reported these two incidents were isolated and there were no prior or subsequent incidents. However, per resident R2’s Progress Notes, there were two incidents where resident R2 was seen touching/caressing other residents in the facility. Additionally, there were two other incidents that were not documented: resident R2 had resident R1 in resident R2’s bedroom, and resident R1 was crying, and resident R2 attempted to touch another resident’s breast area. Based on the investigation conducted by the Department, the preponderance of evidence standard has been met, therefore the allegation, Staff do not prevent inappropriate interactions between residents is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC 9099-D. Exit interview was conducted with Paul Rocha and appeal rights were provided.