Complaint·November 21, 2025

On August 11, 2021, the Department interviewed resident R1’s Family Member (FM). FM stated, R1 told him/her that S1 would stand behind R1 and would put his/her arms across R1’s breast and whisper things such as, “I want to be alone with you, or I know you like this.” FM stated R1 told him/her that he/she didn’t like the touching and if S1 didn’t stop he/she would inform other staff. FM stated, R1 told him/her that this would make S1 slow down for a while but then a few weeks later S1 would pick back up again. FM stated he/she was informed about the inappropriate touching about one year ago. FM stated he/she could not provide a time frame when R1 informed FM when the inappropriate touching started. FM stated R1 told him/her the last straw was when S1 was changing R1 and S1 took his/her finger and stuck his/her finger inside R1’s private. On October 4, 2021, the Department interviewed Staff S1. S1 stated R1 was confused and disorientated due to his/her neurocognitive disorder. S1 denied the allegations and stated he/she never touched R1 inappropriately. S1 stated when he/she showers R1, he/she would lather R1’s body but this was not done in an inappropriate manner. S1 stated R1 requires two people to shower R1. S1 stated one-time R1 had discharge coming from his/her privates. S1 stated R1’s family member was informed, who contacted R1’s doctor. S1 stated R1’s doctor prescribed a medication to treat the discharge. S1 stated the cream was supposed to be inserted into the privates for 3 days. S1 confirmed he/she was the one who inserted the applicator into R1’s privates. S1 stated nothing sexual or inappropriate occurred as it was part of his/her job. S1 stated he/she would hug R1 from behind to pull R1 up in his/her bed. S1 stated there are times when he/she would pull R1 up from the front by grasping around R1’s body and pulling him/her in the bed and adjusting his/her pillow. S1 also denied ever saying inappropriate comments to R1. The Department interviewed Staff S2. S2 stated he/she did help clean R1. S2 stated it would take two people to pick up R1 to get him/her out of bed and into the shower. S2 stated S1 and him/herself work together when lifting R1 and S1 would have to hug R1 to pick up R1. S2 stated whenever R1 was placed on the toilet or shower, both he/she and S1 worked together to lift R1. S2 stated R1 never told him/her that S1 was ever doing anything inappropriate. S2 stated around May 2021, R1 had discharge coming out of his/her privates. S2 stated a cream medication was prescribed. S2 stated the cream was applied inside R1’s privates for 3 days. S2 stated staff S1 applied this cream medication. S2 stated it didn’t bother him/her that S1 was applying the cream medication. Page 2 Out of 3. On October 4, 2021, the Department interviewed residents R1-R3. Residents R2 and R3 stated no one in the facility ever touched him/her inappropriately. R1 stated S1 would take him/her into the bathroom to prepare him/her for a shower and while giving R1 a shower, S1 would move his/her chest up and down and sometimes just hold them. R1 stated other times when he/she was lying in bed, S1 would stand over and put his/her arms across R1 and rock him/her. R1 stated S1 would tell R1 that he/she wanted to be alone with R1. R1 stated S2 never came to the room to assist S2. R1 stated S1 was always putting his/her hands on her/him in an inappropriate way, such as rocking him/her. R1 stated there wasn’t anyone else in the room when this occurred. R1 stated the worst thing that happened was when S1 was changing his/her diaper, S1 took off his/her gloves and put two fingers insider his/her privates. R1 stated he/she does recall having an infection sometime last year. R1 stated he/she could not recall the name of the medication that was prescribed for the infection or how it was applied. Regarding touching the privates, R1 stated S1 was not applying medication to his/her privates. R1 stated this occurred only 1 time. On October 6, 2021, the Department interviewed Licensee (LN) Azila Ortiz. LN stated R1 has confusion and neurocognitive disorder. LN stated R1 is a two person assist, and both care givers must lift and help R1, and one person cannot do it alone. The Department reviewed R1’s Physician’s report dated December 16, 2019. Based on a review, R1 has increased confusion and a neurocognitive disorder. The Department reviewed R1’s Resident Appraisal, dated December 21, 2020. The appraisal states R1 is confused and hallucinates that people are watching him/her and see people inside his/her room. Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegation as UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegation did or did not occur. This Report was reviewed with Administrator Jeremy Bagaoisan . LPA Monter informed Administrator Jeremy Bagaoisan that a PDF copy of the signed report by LPA Monter will be emailed to ADM's for his signature and the original returned to LPA Monter. Page 3 Out of 3.