complaint·January 20, 2026

During the assignment, S2 was initially identified as the alleged perpetrator, and R1 later identified S1; however, both staff denied the allegation. A full investigation was not opened at that time due to insufficient information and inconsistent statements from R1. On 10/03/2025, LPA Huynh conducted an initial complaint visit. Between 3:23PM and 4:07PM, the LPA conducted a physical plant tour and reviewed and obtained pertinent documents. The ED was informed that the complaint allegation was referred to CCLD’s IB. Between 10/06/2025 and 12/29/2025, IB Investigator Rocio Flores conducted interviews with relevant parties including facility staff, residents, and family. Investigator Flores also obtained and reviewed additional documents including hospital records, law enforcement reports, and sexual assault medical examination records. During today’s visit, the LPA and ED conducted a physical plant tour at 12:39PM, and no immediate concerns were observed. The following was then determined: Allegation: “Staff sexually assaulted resident in care” It was alleged that R1 was sexually assaulted by S1. Physician’s Report dated 08/07/2024 documented R1’s diagnoses, including bipolar disorder, schizophrenia, major depression, and mild cognitive impairment. An Individual Service Plan dated 03/17/2025 indicated R1 exhibited confusion, forgetfulness, a history of head trauma, and required staff redirection. R1 reported to Investigator Flores that on 08/02/2025, S1 entered their room and inserted their fingers or genitals into R1’s anus. R1 recalled feeling “internal pain” due to the use of force and expressed uncertainty, stating they may have been “hallucinating.” R1 further stated they were taken to the hospital on 08/06/2025 after Staff #3 (S3) observed blood in their feces. Report Continued on LIC 9099-C S3 confirmed they provided direct care to R1 but denied observing blood in R1’s diaper before, on, or after 08/08/2025. S1 denied the allegation and stated their job duties did not include providing direct care to residents, and that all tasks were documented in a log. S1 reported no conflicts with R1 and described R1 as calm and respectful toward them. S1 reported providing two (2) services in R1’s room between July 2024 and August 2024, and service logs were consistent with this statement. Staff interviews revealed that R1 frequently exhibited inappropriate sexual behaviors towards staff including vulgar comments, hand gestures, and requests during direct care. Staff reported these incidents and expressed discomfort providing care to R1. Staff confirmed that S1 did not provide direct care to residents and described S1 as respectful, caring, and hardworking. Resident interviews supported staff statements and revealed no concerns regarding S1’s conduct and resident interactions. On 08/08/2025, R1 was scheduled for transfer to the hospital for a psychiatric evaluation due to aggressive behavior toward staff. Medical Transportation advised facility staff to contact Emergency Medical Services (EMS) due to low blood pressure. During EMS evaluation, R1 reported they had been sexually assaulted and found blood in their diaper. According to Los Angeles Police Department (LAPD) report, a sexual assault investigation was opened. R1 told LAPD Officers that on 08/07/2025 at 10PM, R1 and S1 engaged in consensual oral sex, that S1 showed R1 pornographic videos, and S1 left the room and did not return. R1 stated they consented only to oral sex and refused to disclose when penetration occurred. R1 also reported that staff observed blood in their diaper the following morning. A sexual assault medical examination was conducted on 08/09/2025. R1 reported losing consciousness during the alleged assault and disclosed penetration and oral sex with S1 but did not provide additional details. A full physical examination—including head, neck, and genital assessment—alternate light source body scan, and oral and genital swabs revealed no findings. The examination did not document or address blood in R1’s diaper. Report Continued on LIC 9099-C An LAPD Detective reported that S1 was eliminated as a suspect because S1 was not on shift during the time R1 reported the incident occurred. LAPD Officers also reviewed facility video footage on various dates and observed S1 entering and exiting R1’s room only for seconds at a time while completing assigned duties, which did not allow sufficient time to commit a sexual assault. The Detective further stated that insufficient DNA evidence also cleared S2 as a suspect. Based on interviews and record review, R1’s statements were inconsistent, and medical examination revealed no findings. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED at this time. No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.