Incident investigation·June 13, 2025

Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent case management visit to deliver findings for the above allegation. LPA met with Rose Anguiano and explained the reason for the visit. On 02/06/2025, the Department received a Report of Suspected Dependent Adult/Elder Abuse and an incident report from the facility. The report advised that on 01/13/2025, Resident #1 (R1) reported to the administrator that on 01/10/2025 Staff #1 (S1) inappropriately touched R1’s private area during incontinent care. The Department referred the case to the Community Care Licensing (CCL) Investigations Branch (IB). The case was assigned to Investigator Dennis Seng to conduct the investigation in reference to the allegation. On 02/07/2025, from 10:45am to 1:15pm, Licensing Program Analyst Zabel Chochian conducted an unannounced Case Management - Incident visit at the facility. Upon arrival LPA Chochian met with Administrator Rose Anguiano. The purpose of the visit was to review records and obtain copies of facility records pertaining to a self-reported incident of alleged sexual abuse received by Community Care Licensing (CCL). It was alleged that on 01/10/2025, facility Staff #1 (S1) sexually abused Resident #1 (R1) by inappropriately touching R1’s private area during incontinent care. During the visit LPA conducted an interview with Administrator, reviewed R1 and S1 records and obtained copies of pertinent documents. Administrator was informed that a referral was made to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Dennis Seng for further investigation. (Continue to LIC809c) On 02/18/2025, from approximately 2:02pm to 3:55pm, Investigator Seng conducted interviews with Administrator, R1, R1’s resident representative, resident, and staff; on 02/19/2025, at approximately 4:06pm, with R1’s roommate; on 04/15/2025, at approximately 1:16pm, with Los Angeles Police Department (LAPD) Topanga Station Detective Brigitta Shapiro; on 04/22/2025, at approximately 3:34pm, with S1; on 04/24/2025, at approximately 4:13pm, with staff; on 05/05/2025, from approximately 12:06pm to 12:43pm, with staff and residents; and on 05/07/2025, at approximately 12:42pm, with Administrator. In addition, Investigator Seng reviewed LAPD Injury Report #25015768 and facility file documents related to the investigation. A review of facility file documents reveals R1 was admitted to the facility on 07/06/2023. R1’s Physician Report, dated 07/01/2023, lists diagnosis of metabolic encephalopathy and nontraumatic subarachnoid hemorrhage. R1 needs assistance with bathing, dressing and toileting; not able to independently transfer to and from bed, non-ambulatory. A review of psychiatric progress notes indicated R1 was seen for routine monthly visits and prescribed medication for major depressive disorder and generalized anxiety disorder. R1’s Appraisal Needs and Service Plan, updated 06/21/2024, documents that “R1 frequently voices wanting to return to Skilled Care. R1 requested a Hoyer lift to transfer and bed rails. Easily becomes upset and anxious, can express rude, mean words to staff. Verbally abusive towards staff, threatening to call Ombudsman and Licensing. Accuses staff of neglect or poor care delivery. Staff reports, R1 can be very disrespectful and will make racist comments”. Based on file reviews and interviews conducted, there was insufficient evidence to prove that the facility was responsible for Sexual Abuse leading to S1 to have an inappropriate sexual contact with R1 while R1 was at the facility. R1’s roommate, facility staff, and S1 denied any sexual abuse occurring with R1 at any time. R1’s roommate stated that S1 was a good caregiver who never acted inappropriately with any residents. S1 stated that they only went into R1’s room to clean R1 as R1 had fecal matter on R1’s vagina. S1 asked R1 for permission to clean R1’s vagina, and R1 consented. S1 added that the contact with R1 was only for to clean R1 and non-sexual in nature. Based on the evidence and interviews conducted, the allegation of “Sexual Abuse: Resident #1 (R1) was sexually abused by Staff #1 (S1)” is deemed Unsubstantiated at this time. Exit interview, copy of report given.