complaint·April 14, 2026

Interviews revealed that over two hours had passed without staff awareness of R1s’ whereabouts prior to the incident. Based on the above information there is sufficient evidence to conclude that staff failed to provide the level of supervision required to prevent the incident. Based on records reviewed and interviews conducted, the facility failed to provide safety and adequate supervision to R2 that resulted in R2 being sexually assaulted. Staff did not prevent a resident from engaging in inappropriate sexual behavior in a common area: Based on interviews conducted and a review of records confirm that Resident, R3, did not require one-to-one supervision and was permitted to access communal areas. R3’s physician’s report documented a history of sexual behaviors and R3 exhibited sexually inappropriate behaviors upon admission to the facility. Staff redirected R3’s sexually inappropriate behavior in accordance with his care plan, regularly notified external providers, and initiated the process that led to their transfer to a specialized Memory Care Facility on 11/4/2025. However, interviews indicate that R3’s sexually inappropriate behaviors occurred significantly more frequently than documented and created a safety risk to other residents. R3 was reported to have been aggressive towards staff and did not respond to redirection. Facility did not increase R3’s level of supervision or modify their care plan to mitigate this risk. There is sufficient evidence to substantiate that staff failed to provide adequate supervision to prevent R3 from engaging in inappropriate sexual behaviors in communal areas. Based on the Departments investigation, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. An immediate civil penalty is being assessed today in the amount of $500 for a violation that resulted in the sickness or injury of a resident in care. The licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code 1569.49(f), or 1548(e) or (f), 1568.0822(f) Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Machellee Allison and Appeal rights were given.