Complaint·June 27, 2022

Continued from 9099 LPA conducted a second subsequent visit; at which time, LPA conducted interviews with additional staff, former staff and a family member of R1. LPA also reviewed and obtained copies of additional documents pertinent to the investigation. On 03/23/2022, the case was referred to Community Care Licensing Divisions Investigations Branch (IB) to obtain the forensic exam results and police report pertaining to R1. On 04/08/2022, IB Investigator Sonia Sandoval received and reviewed forensic exam records from the Rape Treatment Center. Moreover, on 05/03/2022, IB Investigator Sonia Sandoval received and reviewed police report from Los Angeles Police Department (LAPD). After numerous attempts 1/21/2020 at 2:30pm , 3/16/2022 at 1:30pm, 4/21/2022 at 4:30pm, 4/23/2022 at 3pm,to contact S1, on 05/27/2022, between 2:30p.m. and 4:00p.m., LPA interviewed S1. Information gathered during the course of the investigation revealed that no current or former staff has ever witnessed S1 sexually abuse R1. The IB investigator’s review of the forensic exam records from the Rape Treatment Center revealed that on 04/05/2019, a forensic exam was conducted on R1, which resulted in no positive findings that a rape had occurred. Interview with a family member of R1 revealed that R1 was admitted into the hospital on approximately 04/05/2019, for an infection in their private area. The family member stated that hospital staff informed them that there was no physical evidence, such as abrasions or tissue damage on R1, to indicate that sexual abuse had occurred. Furthermore, hospital discharge records revealed there was not enough evidence to confirm that sexual abuse had occurred. Belmont Village Hollywood management, which included Executive Director and Human Resources conducted an internal investigation, which included interviewing sixteen (16) staff members who had worked with S1 and R1. Per records reviewed, facility internal investigation concluded on 04/19/2019. Additionally, a review of the internal investigation revealed that S1 denied all allegations of sexual abuse against R1. Based on all information gathered during the internal investigation facility was unable to substantiate the allegation. Furthermore, the IB Investigator’s review of LAPD police report revealed that R1 was unresponsive to LAPD officer’s questions during their investigation. The LAPD officer was informed by R1’s family member that due to R1’s diagnosis, R1 did not respond to anyone. The family member further revealed to the officer that R1 was admitted to the hospital due to an unusual discharge from R1’s private area. The report also indicated that approximately four (4) months ago, R1 was experiencing the same unusual discharge and treated for an infection. Continued from 9099-C S1 denied any sexual abuse had occurred with R1 while S1 was employed at this facility. Furthermore, S1 denied ever assisting R1 with the lights turned off in R1s room, and also denied ever being witnessed by any staff member, assisting R1 with the lights turned off in R1s room. Additionally, S1 provided a signed declaration denying any wrongdoing or sexual abuse against R1. Based on the information gathered during the course of the investigation, the Department does not have sufficient evidence to support the allegation that R1 was sexually abused by S1. Therefore, the above allegation has been deemed UNSUBSTANTIATED at this time. It was also alleged that there were two (2) staff who lacked a criminal record clearance and association to the facility that were working in the facility. The LPA’s record review of the employee files for S1 and Staff #2 (S2), revealed that both employees were cleared and associated to work at the facility, at the time of the investigation. The LPA record review of the Facility Personnel Report revealed that personal identifying information such as Date of Birth, Driver’s License and Social Security number for S1 and S2 matched what facility had on file for each employee. The LPA’s interviews with current and former staff revealed that S1 was the only employee with the name mentioned as an uncleared adult. Based on the interviews and documentation obtained and reviewed, the Department does not have sufficient evidence to support the above allegation that there are ‘Uncleared Adult(s) working in the facility’. Therefore, the above allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted. Report issued and sent via email. Continued from 9099 LPA conducted a second subsequent visit; at which time, LPA conducted interviews with additional staff, former staff and a family member of R1. LPA also reviewed and obtained copies of additional documents pertinent to the investigation. Information gathered during the course of the investigation revealed that the first suspected sexual abuse/inappropriate behavior by Staff #1 (S1) was reported to the facility management on 06/29/2018. Additionally, a second allegation of sexual abuse/inappropriate behavior was reported on 10/04/2018. Records reviewed and interviews conducted revealed that the facility conducted an internal investigation regarding the alleged incidents between 06/29/2018 and 07/03/2018. However, facility did not submit a Special Incident Report (SIR) to Community Care Licensing (CCL) or Suspected Dependent Adult/Elder Abuse form (SOC341) to the all appropriate agencies for either of the above incidents. Based on all information gathered, the above allegation, “facility failed to meet reporting requirements” is deemed SUBSTANTIATED at this time. It was further alleged that facility staff failed to seek resident timely medical attention. It was reported that facility failed to obtain appropriate medical attention after the initial suspected sexual abuse allegation. Interviews conducted and records reviewed did not reveal any evidence that R1 was evaluated by any medical professional after the suspicions that R1 may have been sexually abused. Based on interviews and documentation obtained and reviewed, the Department has sufficient evidence to support the above allegation. Therefore, the above allegation that, ‘Facility staff failed to seek resident timely medical attention’ has been deemed SUBSTANTIATED at this time. It was further alleged that the facility failed to protect resident from harm. It was reported that after the suspected concerns regarding inappropriate behaviors was reported, management continued to let S1 assist R1. Information gathered during the course of the investigation revealed that concerns of possible sexual abuse/inappropriate behaviors was initially reported on 06/29/2018. Continued from 9099-C Records reviewed and interviews conducted revealed that the facility conducted an internal investigation regarding the alleged incidents between 06/29/2018 and 07/03/2018. The internal investigation conducted reflected that there was no indication that S1 was spending inappropriate time with any resident. However, management was to continue monitoring S1. A second allegation of sexual abuse/inappropriate behavior towards R1 by S1 was reported to management on 10/04/2018. Information gathered during the course of the investigation revealed that S1 was never reassigned to a different department, even though there was an allegation of sexual abuse/inappropriate behavior towards R1 by S1 on two different occasions. Furthermore, review of the employee file for S1 revealed that S1’s last day of onsite was 03/31/2019. Facility “Daily Check-in” logs further revealed that S1 was providing care and supervision to R1 up to 03/31/2019, which was nine months after the initial allegations. LPA interview with Executive Director revealed S1 was suspended on 4/5/2019, as the facility conducted an internal investigation for the sexual abuse allegation. Interview further revealed that S1 did not return to work for this facility at the conclusion of their investigation. Based on the information gathered, the Department does have sufficient evidence to support the above allegations. Therefore, the allegations that “facility failed to protect resident from harm” has been deemed SUBSTANTIATED at this time. Citations issued (please see 9099-D), appeal rights given, exit interview conducted. Report issued and sent via email.