complaint·October 24, 2025

Investigation Revealed the Following: Allegation: Staff sexually assaulted a resident while in care The details of the complaint alleged that facility staff (S#1) sexually assaulted (R#1) at the facility. On October 17, 2025, at approximately 1:00 PM, during a records review, the department found a copy of Long Beach Police Department (LBPD) report #250025649, dated June 8, 2025. This report details an incident where, on June 8, 2025, at around 4:00 PM, LBPD officers responded to a memory care unit following a report of sexual assault. The report indicated that the victim (R#1) claimed to have been sexually assaulted by the suspect (S#1). LBPD officers interviewed (R#1), who stated that approximately three weeks prior, (S#1) had entered their room twice to administer medication once around 9:00 PM and again around 10:00 PM. (R#1) mentioned that the following morning, they woke up experiencing significant vaginal pain. During the interview, (R#1) provided a tissue that they had used to clean their private area. A Sexual Assault Forensic Medical Exam (SART) was subsequently performed on (R#1), but the examination revealed no physical findings. Additionally, the department reviewed the copy of (R#1)'s Physician's report for Residential Care Facilities for the Elderly (RCFE) dated 6/9/25. The department observed that (R#1) has a cognitive impairment that might influence their decision-making and behavior. On 8/28/25, at approximately, 9:45 am, the Department interviewed facility administrator (A#1), she stated that when (R#1) move into the facility, they were placed in the assisted living section, however, it was determined that (R#1) needed a higher level of care, therefore, (R#1) transitioned to the memory care unit and resided there for approximately four weeks before moving out. Evaluation Report continues LIC 9099-C On September 4, 2025, at approximately 11:00 AM, the Department interviewed Facility Staff #1 (S#1), who confirmed that they were the medication technician assigned to the Memory Care Unit (MC1), where Resident #1 (R#1) resided. At around 7:00 PM, (S#1) attempted to administer medication to (R#1), who refused to take it. The medication was subsequently discarded, and the refusal was documented in the electronic log. (S#1) denied having any physical contact with (R#1) during that shift or previous shifts. (S#1) also denied the allegation of sexual assault, expressing confusion and attributing the claim to (R#1)'s cognitive impairment and possibly the missed medication. On August 4, 2025, at approximately 3:00 PM, the Department interviewed Witness #1 (W#1). (W#1) stated that (R#1) had lived at the facility for about six weeks. (R#1) initially moved into the assisted living unit but was later transferred to the memory care unit for 24-hour care. (W#1) reported being notified of the incident by the police. When asked, (R#1) told (W#1) that someone was entering their room and sexually assaulting them. (W#1) expressed doubt about the allegations but chose to wait for the results of the Sexual Assault Forensic Medical Exam (SART). (W#1) also recalled that about two weeks after (R#1) moved in, (R#1) made a similar disclosure but was unable to provide further details. (W#1) believed the statements may have been influenced by (R#1)’s cognitive impairment. On August 5, 2025, at approximately 10:00 am, the Department interviewed Resident #1 (R#1), who was unable to recall how long they had lived at the facility. (R#1) shared that before admission, they had experienced a fall that resulted in hospitalization, after which they began noticing a gradual memory decline. When asked if they knew the reason for the interview, (R#1) stated they did not. When asked if anything had occurred to them at the facility, (R#1) stated that several things had happened during their stay. (R#1) reported believing they had been sexually assaulted, explaining that they noticed some residue coming from their private area. (R#1) was unable to recall any additional details about the alleged assailant or the incident. Evaluation Report continues LIC 9099-C On August 28, 2025, at approximately 11:00 am, the Department interviewed residents 2-4 (R#2-R#4), (2) out of (3) stated that they feel safe living at the facility and the facility staff are ‘good’ to them. On August 28, 2025, at approximately 10:00 am, the Department interviewed facility staff 2-5 (S#2-S#5), (4) out of (4) stated that they have never observed (S#1) or other facility staff interact inappropriately with (R#1) or any other residents in care. During this investigation, LPA did not find sufficient evidence to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Peggy Clark/Administrator.