complaint·July 2, 2025

(PAGE 2) Report continued from LIC 9099... On 01/28/2025, the assignment was upgraded to a full investigation. Subsequently, on 02/20/2025, the RO received a complaint pertaining to the same allegation. On 01/09/2025, from 12:02pm to 3:00pm, Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced Case Management visit regarding the self-reported Unusual Incident/Injury Report (UIR) incident report received on 01/08/2025. The UIR pertained to an incident that allegedly occurred between R1 and S1. LPA Byrne met with Executive Director (Administrator) Lito Vitug at 12:02pm and explained the reason for the visit. During the visit, the LPA conducted an interview with the Administrator, conducted a brief physical plant tour, and obtained copies of pertinent information. The LPA informed the Administrator that a referral was submitted to CCL’s Investigations Branch and assigned to Investigator Veronica Padilla. The LPA determined further investigation was needed prior to issuing findings. On 02/26/2025, from 9:30am to 3:20pm, Licensing Program Analyst (LPA) Erica Mosley conducted an unannounced initial complaint visit to the facility. At 9:35am, LPA Mosley met with Rizaandrea Vitug, Assistant Administrator, and explained the reason for the visit. The Executive Director (Administrator) Lito Vitug arrived during the visit. On 02/20/2025 the Department received a complaint alleging staff do not ensure that resident is treated with dignity and respect and a personal rights violation. The personal rights violation is in relation to the self-reported Unusual Incident/Injury Report (UIR) received on 01/08/2025 regarding R1 and S1. The initial visit was conducted on 01/09/2025 by LPA Trevor Byrne. A referral was submitted to Community Care Licensing Division's (CCLD) Investigation Branch (IB) and Investigator Veronica Padilla was assigned to investigate the personal rights violation. At 9:40am, LPA Mosley, along with the Assistant Administrator conducted a physical plant tour to ensure there were no immediate health and safety concerns. From 10:30am to 2:30pm, the LPA conducted interviews with ten (10) residents and six (6) staff including the Administrator and obtained copies of pertinent documents relevant to the investigation. The LPA determined further investigation was needed prior to issuing findings. On 01/28/2025, from approximately 10:30am to 12:50pm, Investigator Padilla conducted interviews with Resident #1 (R1), residents, and Administrator; on 01/30/2025, at approximately 11:00am, with Los Angeles Police Department (LAPD) Detective; on 02/20/2025, at approximately 9:30am, with Administrator; on 03/11/2025, from approximately 9:00am to 2:51pm, with LAPD Detective, and former facility med tech; Report continued on LIC 9099C PAGE 3.... (PAGE 3) Report continued from LIC 9099-C PAGE 2... On 03/12/2025, from approximately 9:23am to 2:10pm, with former caregiver, residents and staff; on 03/20/2025, at approximately 2:50pm, with former med tech; on 03/21/2025, at approximately 1:30pm, with Long-Term Care Ombudsman (LTCO); on 03/28/2025, from approximately 11:40am to 2:00pm, with former residents and former caregiver; on 04/08/2025, from approximately 8:20am to 12:51pm, with former resident, residents, caregivers, facility manager, and Staff #1 (S1); on 04/16/2024, at approximately 2:10pm, with LTCO; on 04/23/2025, at approximately 11:05am, with Administrator; and on 04/24/2025, at approximately 11:20am, with Staff #2 (S2). In addition, the investigator reviewed LAPD Report #25-003466, facility Ring video footage, and facility file documents pertaining to the investigation. According to R1’s Physician Report, dated 10/02/2024, R1’s primary diagnosis is listed as debility and neuropathic pain; the second diagnosis is listed as chronic hypokalemia, depression, hypothyroidism, leukemia, migraine, osteo arthritis, peripheral neuropathy, scoliosis s/p lumbar; R1 can manage own treatment, medication and equipment; mental condition is listed as R1 can follow instructions, communicate needs, and leave the facility unassisted. R1 is ambulatory. The review of the facility staff schedule, laundry schedule and service log revealed the following: According to the facility staff schedule, S1 works the AM shift (7:00am to 3:30pm) and S2 works the NOC shift (11:30pm to 8:00am). The laundry schedule noted that R1’s laundry service was scheduled on Saturdays during the PM shift (3:00pm to 11:30pm). The service log report does not show any service log entries (including laundry service for R1) for 12/29/2024. The review of the facility Ring video revealed that on 12/29/2024 at 11:09pm – S2 stepped out of the stairwell door and walked toward R1’s room, standing in front of the door as S2 retrieved the key from S2’s right pocket. At 11:12pm, it appears that S2 is closing and locking the door to R1’s room, walking down the hallway, and entering another room without knocking. The facility manager confirmed that the person in the video entering R1’s room was S2. It was discovered that S1 did not enter R1’s room during the night of 12/29/2024. R1 likely confused their names due to their similar appearances. On March 11, 2025, Investigator Padilla reviewed LAPD Report #25-003466. On the allegation “Staff #1 (S1) sexually assaulted Resident #1 (R1)” During the Department’s investigation, Investigator Padilla determined that S1 was not the suspect, despite R1 labeling S1 as such due to S1’s similar appearance as S2. Report continued on LIC 9099C PAGE 3.... (PAGE 4) Report continued from LIC 9099-C PAGE 3... Based on the time and date given by R1, along with the facility video footage, Investigator Padilla identified S2 as the person who entered R1’s room during the assault on 12/29/2024 at 11:09pm. Resident #2 (R2) stated on the night of the incident, R1 came to R2’s room at approximately 11:30pm crying and stating that someone had come into their room and jumped on top of R1, kissing and licking R1. On 02/07/2025, the LAPD detective created a photographic lineup that placed S2 in the number three position, and R1 selected S2 from that position. The Administrator Angelito (Lito) Vitug and facility manager Joselito (Joey) Vitug acknowledged that R1 did not call for help on the night of the incident. The service log report does not show any service log entries (including laundry service for R1) for 12/29/2024. The Administrator admitted that completing a laundry task should have taken less than a minute, but if the resident declined laundry services, the caregiver should leave the room, which only takes seconds. On the afternoon of 12/30/2024, the Administrator reviewed the facility Ring video footage and discovered that S2 had entered R1's room the night before. The facility supervisor, admitted that they and the Administrator and facility manager, were aware that S2, not S1, entered R1’s room that night. However, the Administrator chose not to disclose this information to CCL and the police. The Administrator instead wrote an unusual incident report (UIR) under S1’s name, withholding details about S2. The licensee will be cited for reporting requirements under a separate report. On 12/29/2024, S2 was scheduled to start work at 11:30pm. However, S2 entered R1’s room at 11:09pm and was there for approximately three minutes before S2’s shift. S2 stated that S2 started work early to get R1’s laundry. When Investigator Padilla informed S2 that it was not R1’s scheduled laundry day; S2 said, “It was a mistake on my part.” S2 denied the allegation. The facility suspended S2 and S2 is no longer associated to the facility. Based on the Department’s investigation, there was sufficient evidence to support that R1 was sexually assaulted by S2. Therefore, the allegation is deemed Substantiated at this time. The following deficiency was observed (See LIC 9099-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Assistant Administrator was made aware that failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided. (PAGE 2) Report continued from LIC 9099... On the allegation Staff do not ensure that residents are treated with dignity and respect it is the concern of the reporting party (RP) that Staff #5 (S5) and Staff # 6 (S6) retaliated against R1 and told male clients not to go near R1 because they will file a complaint. To investigate this complaint on 02/26/2025 starting at 10:30 a.m. LPA conducted interviews with ten (10) residents including R1, six (6) staff including S5, obtained copies of pertinent documents relevant to the investigation, and on 04/07/2025 at 2:45 p.m. conducted a telephonic interview with a resident. Interview with R1 revealed that they noticed a shift in the staff and resident’s interactions starting in January 2025. R1 stated that Resident #2 (R2) was unresponsive and believes its due to S5 and S6. Interviews with residents revealed that they have positive remarks and experiences with S5 and S6. Residents state that the staff have never discouraged or instructed them not to interact with anyone at the facility including R1. Male residents state they never been discouraged or instructed by staff to not interact with anyone at the facility including R1. Furthermore, R2 stated that they decided on their own to distance themselves from R1, expressing that they did not want to be involved in any conflict or drama. Interviews with staff revealed that R1 tends to behave in a rude and disrespectful manner. Despite occasional behavioral challenges, staff continue to treat R1 with dignity, respect, and professionalism. Staff state that S5 and S6 maintain a professional demeanor and positive interactions with residents including R1. Interview with S5 revealed that there has been no retaliation against R1 by staff or administration. At no point were male residents instructed to avoid interacting with R1 out of concern that they might file a complaint. 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 of Staff do not ensure that residents are treated with dignity and respect is deemed unsubstantiated at this time. Exit interview conducted. Report was reviewed and a copy was provided.