complaint·June 13, 2025

9099C-1.. Allegation: Staff had an inappropriate interaction with resident. The allegation states that staff (S1) had an inappropriate interaction with resident (R1). NOTE: The Department conducted the investigation for the above allegation and separate interviews were conducted for this allegation from the interviews the LPA conducted for the other (3) allegations. Resident (R1) stated that staff (S1) would "rub up against" them and explained when (S1) assisted (R1) from getting up from bed, (S1) would rub up against their back. (R1) stated (S1) would have their clothes on while rubbing up against them and then pull open their "stretchy pants" and lean forward, exposing their private parts to (R1). (R1) stated that (S1) exposed themselves "twice" but would rub up against them "a lot", adding that when they asked (S1) to stop this type of interaction, (S1) would not, so (R1) reported it to the Administrator. (R1) stated Administrator, Veronica, spoke to (S1) about this and now (S1) is not allowed to take care of (R1) anymore. (R1) stated no other staff has exposed themselves to (R1) and has never seen (S1) expose themselves to another resident, commenting they "feel safe" at the facility. Administrator, Veronica Morales, stated she does not believe staff, (S1) exposed themselves to (R1), explaining she has never had any complaints about (S1) before or an issue with (S1) spending too much time in a resident's room. The administrator stated that in the beginning of April 2025, (R1) reported that (S1) was "exposing" himself to (R1) and asking if they could shower (R1). The Administrator stated that (R1's) family members informed her that (R1) has made similar comments while living at other care homes. The Administrator stated she spoke to (S1) in her office about these allegations and (S1) stated it "never happened" although (S1) acknowledged permitting (R1) to use their cell phone to make a call. The administrator explained that she initially decided to reassign (S1) to another section of the facility so they do not provide any care (R1). Additionally, (S1) is not allowed to be close to (R1) or be in their room. The administrator stated that (S1) is "very respectful and a hard worker" and (R1) has not mentioned this incident in subsequent conversations. The administrator stated that (S1) has relocated to a "sister facility" as of 6/11/25, as there was an opening in that related facility. Multiple (3) residents stated in interviews that no staff has ever made them feel uncomfortable or made them do anything they didn't want to do. These residents denied ever hearing about a staff exposing themselves to them or any other resident. *cont on 9099C-2.. 9099C-2 .. (S1) denied ever touching (R1) with their private parts, exposing their private parts to (R1), or ever having any interaction with (R1) that could have been mistaken for (S1) exposing or touching (R1) in this way. The family member stated that (R1) "can be confused and have hallucinations" stating "I think (R1) had a lot of dreams they thinks are true and also sexualizes a lot of things- lots of weird stuff", which may be common for "baby boomers". Based on information obtained, the above allegation is found to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Allegation: Staff did not safeguard resident's personal items. The allegation states that resident’s (R1) belongings and money have been stolen from their room. On 4/2/25, the Department received additional information that staff are not safeguarding resident (R2's) personal items. The Administrator, Veronica, stated on 3/27/25 she is not aware of any of (R1's) belongings that are missing, including money and confirmed (R1) has a cell phone and has also used the facility phone too. The administrator commented that (R1) "gets confused and then forgets" and has a diagnosis of Dementia and Diabetes. On 5/20/25, the Resident Care Coordinator (RCC) stated that (R1) has not had any items go missing, including a cell phone, and that (R1) lives in a shared room and has called 9-1-1, Community Care Licensing, Adult Protective Services, and the Ombudsman "many times". The RCC stated (R1) is "pretty high functioning and got mad because their daughter won't let them leave to go to church". (R1) stated to LPA on 5/20/25 that the RCC has the list of missing items and "right now I am missing a cane, 4 white towels/washcloths and 27 pairs of white garment bottoms"- (R1) stated she is also missing deodorant and facial scrub and thinks it's "another resident taking her things". (R1) added that her family member took her cell phone because of calls made to Adult Protective Services and the police. On 5/27/25, (R1's) family member stated that (R1) does not have anything of value, including cash, and there is "nothing she is concerned with". The family member indicated she does not recall (R1) having a cane and their needs are being met. When LPA stated (R1) has claimed their laundry has disappeared, the family member stated all of (R1's) items are labeled and she visits (R1) twice weekly and she feels "staff is doing a good job". The family member commented that (R1) is "very paranoid" and it's "been magnified" since (R1) has been diagnosed with Dementia. The family member added that (R1) "can be confused and have hallucinations", which may be common for "baby boomers". *cont on 9099C-3. 9099C-3.. On 5/20/25, the RCC stated that resident (R2) had a prior conservator before a public conservator was appointed. The RCC stated the family member would bring new clothes and remove torn or stained clothing from (R2's) closet every time he visited, every 2 months. The RCC stated the socks (R2) moved in with were "not compression stockings" but were just tall socks, and the Ombudsman came out to investigate the lost socks. LPA was unable to contact this family member, after two attempts. LPA was provided with a list of missing items on 4/10/25 and attempted to contact the prior conservator for (R2) regarding the missing belongings on 4/10/25 but was unable to. The complaint alleges that a list of missing items was provided to the facility on 3/20/25, and the facility was going to look for them, but nothing had been found as of April 1, 2025, and all items were labeled with resident's name. The list includes pants, blouses, laundry basket, blanket, diabetic compression socks, a wallet, and false teeth. LPA discussed the missing items with the administrator more in detail on 6/13/25. The administrator stated she checked (R2's) room in early April 2025 with the RCC after the Ombudsman came out to investigate, and the items were not found in (R2's) room. Additionally, the RCC discussed these missing items at a staff meeting. All that was found was a wallet with identification belonging to another resident (R3), who had since moved out. The family was contacted for (R3). Based on information obtained, the above allegation is found to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview. Copy of report provided. 9099A-C-1... The administrator stated that all mail is received at the front desk, residents are informed by staff, and then residents will pick up their mail at the front reception desk. The administrator explained that the families receive most of the important mail, but some residents do receive mail. The administrator confirmed that all monthly bills have been paid by (R1's) family members, and there is no balance currently owed to the facility. This information is still correct as of June 13, 2025. On 5/20/25, the administrator stated that (R1) does receive some mail, but staff will hold it and give it to her two family members who visit regularly. The RCC stated on 5/20/25 that (R1) receives mail from two agencies related to their finances, and that she has asked (R1's) daughters to change the address so this mail will not continue to be received by the facility. The RCC stated (R1) has dementia and so this type of mail should go to the family member who holds Financial Power of Attorney. Resident (R1) stated on 5/20/25 that they have not received any mail while staying at the facility, and confirmed the name of their family member who holds Financial Power of Attorney. LPA contacted this family member who confirmed, on 5/27/25, that (R1's) mail is still being sent to the facility address and (R1) wasn't giving (R1's) their important, financial mail to her when it was received at the facility. This family member added that the facility is doing a good job of collecting (R1's) mail and holding it for her when she visits two times weekly and that (R1) has not received any personal mail, such as greeting cards, while living at the facility, but "(R1's) church members have brought them gifts" in person. This family member stated on 5/27/25 that (R1's) bills are current (with no balance) and last month, she provided an outside agency with copies of bank statements showing (R1's) deposits and expenses. The family member confirmed that she stopped paying (R1's) credit card balances, in August 2024, per advise from a financial advisor, and there was a balance owed, as stated in the complaint allegation. LPA was unable to contact the representative from the outside agency for any additional information. Based on information obtained, LPA finds the allegation to be UNFOUNDED-meaning that the allegation was false, could not have happened and/or is without reasonable basis. *cont on 9099C-2... 9099A-2.. Allegation: Staff do not assist resident with obtaining medical care. The allegation says staff is complicit with (R1's) family members who are restricting (R1’s) access to medical care. (R1) stated to LPA on 5/20/25 that their daughters have access to their medical account and that their unpaid bills are affecting their access to medical care. The administrator stated that "there are no issues with medical" services for (R1) and that (R1) is receiving all medical benefits and services she is entitled to. Charting notes document that when resident moved in on December 9, 2024, the RCC was working with (R1's) family member to start home health services. There are no issues noted that (R1) did not receive any medical care but many entries where (R1) was questioning and/or refusing medications ordered for them to take. On 5/27/25, the family member who has Power of Attorney authorization stated (R1) is off insulin and is a "lot healthier" since moving to the facility; however, she is not happy; commenting, (R1)"can be confused and have hallucinations" and stated "I think she had a lot of dreams she thinks are true and also sexualizes a lot of things- lots of weird stuff", which may be common for "baby boomers". This family member stated (R1) had "18 falls since May 2024", including when living on their own, and uses a walker, as recommended, and commented after (R1) had 3 falls in a week and was on the floor for (8) hours, while living on their own, so she and her sister realized (R1) needed assistance. Based on information obtained, LPA finds the allegation to be UNFOUNDED-meaning that the allegation was false, could not have happened and/or is without reasonable basis. Exit provided. Copy of report provided.