complaint·May 21, 2025

The investigation determined the following: Regarding the allegation: Resident was sexually assaulted at the facility. It was alleged that Resident 1 (R1) was sexually assaulted by three (3) staff members. Interviews with R2-R8 stated that they have never heard nor witnessed any staff member sexually abuse residents. Interview with R6 revealed that they have heard R1, “…talking or screaming to the voices in their head”. Interviews with S1-S8 confirmed that they have not witnessed or heard of any residents having been sexually assaulted from staff members. Interview with the Administrator revealed that when R1 was discharged from the hospital they returned to the facility. When the facility became aware of the alleged incident, the Administrator stated they proceeded to conduct their own internal investigation as well as reporting the incident to the appropriate domains. LPA’s record review confirmed that a Report of Suspected Dependent Adult/Elder Abuse was submitted on 4/03/2025 to Adult Protective Services (APS). During a record review, LPA observed on 4/10/2025 SIA Luckett obtained the police report from the Special Victims Unit (SVU) where it stated that R1 was, “…scheduled to undergo a forensic sexual assault examination” but R1 later refused. Confirmation of refusal of the examination was confirmed on 4/29/2025 when SIA contacted the subpoena desk at Antelope Valley Medical Center regarding R1’s forensic exam where it was revealed R1 refused the exam. Additionally, on 4/10/2025 SIA subpoenaed R1’s medical records from Antelope Valley Medical Center. LPA’s record review revealed that R1 has various mental health disorders. Unusual Incident Reports (SIRs) were submitted to CCLD which show R1’s history of requesting to be sent to the hospital due to hearing voices and not feeling mentally well. LPA’s review of the police report noted that R1’s story regarding the allegation was, “…often changing and contradicting”. LPA’s review of medication revealed that R1’s care plan includes various medications which can cause side effects such as: agitation, suicidal tendencies, and/or vivid dreams such as nightmares. Furthermore, based on interviews, record reviews and SIA’s investigation there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards were noted during the visit. Exit interview was conducted and a copy of the report was provided to the Administrator.