Complaint·January 23, 2024

Allegation: Resident was sexually assaulted while in care. It is alleged that resident (R1) was raped at the facility by an unknown perpetrator. Investigations Branch (IB) investigator L. Garcia conducted the investigation. Resident (R1) only resided at the facility a total of four (4) days [6/10/22 - 6/14/22], and there were no complaints reported to staff of alleged sexual abuse. A total of six (6) staff were interviewed, of which all denied having knowledge of alleged rape/alleged sexual abuse of resident (s). Staff revealed that there are some residents that are intimate with each other and in a relationship. It is assumed their relationship is consensual because no reports of rape or sexual abuse have been report. Per file review, R1 has history of schizophrenia and paranoia. Staff (S3) stated that on one occasion they witnessed resident (R1) saying that a man was behind trying to kill the resident, but there was no one around. Resident (R1) was not interviewed because they moved out, and after several attempts to contact R1, and interview was not possible. IB investigator interviewed residents (R2 & R3); both denied sexual abuse or knowledge of sexual abuse incidents. A law enforcement search inquiry was made, however, no relevant information or current address location was obtained for resident (R1). Based on interviews conducted and record review, the findings indicate that there is insufficient evidence to corroborate the allegation. Allegation: Residents are being mentally and physically abused by staff. It is alleged that staff hit residents and are verbally abusive to residents. It was reported that in the past one (1) staff (S7) fought with a resident (unknown name) with their fist. It is also alleged that supervisor/staff (S3) has been overheard calling resident(s) "bitch". It was also reported that a night shift staff (S8) accidentally dropped resident (R2), and that supervisor/staff (S3) and S8 told R2 to say they were hit and not dropped. Three (3) staff, [staff S2, S3, and S7] were reported to be verbally and physically abusive to residents. Staff (S2 & S3) denied the witnessing or engaging in abuse. Administrator/staff (S1) stated that two (2) staff were fired the week prior to this complaint being filed, and they told Administrator they were going to file a complaint. A copy of Employee Disciplinary Action Form was provided to investigator, stating that staff (5) was fired due to threats and harassment of residents. A total of two (2) residents were interviewed, both R2 & R3 stated that they have not been victims of mental or physical abuse. Resident (R2) denied sustaining injuries from either neglect or abuse by any of the staff members, and also denied ever witnessing any type of abuse by any of the staff or residents or hearing any rumors of abuse. One (1) out of six (6) staff interviewed stated that staff are verbally and physically abuse. However, there is insufficient evidence to prove the allegation. *See next page. Allegation: Residents needs are not being met by the facility. It is alleged that residents are not being provided feeding assistance, receiving incontinence care as directed, staff do not wash the resident's clothes, and are not being provided transfer assistance into their wheelchairs. A total of six (6) staff were interviewed, of which all denied neglect of care and supervision. According to staff, non-ambulatory residents are assisted with incontinence care, bathing, and basic needs. A total of six (6) residents were interviewed. Resident interviews revealed that staff assist with Activities of Daily Living (ADL's) as required, and that they are satisfied with the level of care provided by staff. Based on interviews conducted and record(s) review, there was insufficient evidence to prove the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are UNSUBSTANTIATED . Exit interview was conducted with Roxana Aparicio. *Only the 1st page of the report was printed. There were printing technical issues. The entire report will be emailed & mailed.