complaint·March 29, 2024

Records reviewed and interview conducted with staff on 08/14/2023 from approximately 10:05am-11:45am, confirmed that above alleged incident was not reported. Therefore, based on the information obtained during this investigation, there is sufficient evidence to support the claim that staff failed to follow through with alleged investigation in timely manner. This allegation is Substantiated at this time. Pursuant to Title 22, California Code of Regulation, the following deficiency is cited (refer to LIC 9099-D). Exit interview conducted. Appeal rights provided. Copy of report provided. On 08/16/2023, from approximately 1:55 p.m.-2:45 p.m., IB Investigator Douglas Real interviewed facility Administrator and the two (2) staff. On 08/17/2023 at approximately 2:20 p.m., IB Investigator Douglas Real interviewed R1’s responsible party. R1 passed away on 06/24/2023 and was not interviewed. Staff interview revealed that sometime in November 2022 the facility was notified by R1’s family that R1 had reported being sexually assaulted by two (2) male facility employees while being showered. The facility director at the time was Ilene Owens and she investigated the matter and interviewed the staff. The staff denied the allegation, and nothing was uncovered suggesting there was any merit to the allegation. Staff reported that R1 had dementia, was combative on occasion, and did not like to bathe or shower. R1 frequently needed two-person assistance, especially with showers. Staff reported that R1 dementia was bad, and R1 was often confused. Staff denied the allegation. Interview with the R1 responsible person (RP) revealed that R1 had dementia and was frequently confused. R1 did not like showering or bathing but needed to be cleaned. It took two (2) caregivers to shower R1 and it was very difficult getting R1 to shower. Sometime in November 2022, R1 was showered by two (2) staff, and R1 claimed staff raped R1. RP stated that they had known the two staff as they had worked with the R1 at another facility, and they had always provided a good level of care. R1 had never made an allegation like that before. After the allegation, they took R1 to be checked by a doctor at an urgent care and the doctor found no evidence of a sexual assault. According to RP, the facility Administrator at the time was notified of the allegation and investigated the allegation. Staff were questioned and the staff denied the allegation. RP saw nothing at the time to suggest the R1 had been assaulted and RP does not believe that R1 was raped. Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the above allegation “Resident was sexually assaulted by staff” is deemed UNSUBSTANTIATED at this time. Exit interview conducted. A copy of the report was provided.