complaint·June 28, 2022

R1 tried to scream, and the man placed his hands on R1’s mouth and told them not to scream or he would hurt R1. The man moved R1’s wheelchair and stood beside R1’s bed pleasuring himself and asked R1 to perform a sexual act. Interview with staff revealed that on February 4, 2020, at about 6:10am a caregiver was alerted that R1 pushed their pendant button and needed assistance. As the caregiver attempted to open R1’s door the unknown man was pushing against it to prevent her from entering. When she entered the room, she asked the man what he was doing there and struck him several times in the head. The suspect then ran out of the building. R1 advised the caregiver that the suspect tried to rape them, and the caregiver noticed R1’s pajamas and underwear were on the floor at the end of their bed. Interview with the Executive Director (ED) revealed the incident occurred in the middle of shift change. ED stated that the facility doors open at 6am and close at 7pm. ED also stated that there was no one at the front desk at 6am since the front desk worker starts at 7am. ED agreed that anyone could walk in the facility and no one would see them. After review of interviews from R1, staff and outside agency, it is evident that the lack of supervision and safety protocols resulted in the attempted rape of R1 and therefore the above allegation is substantiated. This finding means that the preponderance of the evidence standard has been met and the allegation is valid. Deficiency is cited in accordance with California Code of Regulations, Title 22. On February 6, 2020, the facility reported to Community Care Licensing an unwitnessed fall which resulted in serious bodily injury of Resident 1 (R1). Subsequently it was alleged that R1 suffered a fall that resulted in subdural hematoma on February 4, 2020. Interview with staff revealed at around 1pm, R1 called out verbally for assistance after falling. Three caregivers went to R1's room and found them on the bathroom floor. R1 advised staff that they fell while brushing their teeth. Staff stated R1 can pull themselves up out of the wheelchair and R1 prefers to do things on their own. Interview with R1 revealed they were in their wheelchair and wheeled themselves to the bathroom, to brush their teeth. When asked why they didn't call anyone for help, R1 stated they wanted to do it on their own. R1 stated the brakes were not engaged on the wheelchair and their hand slipped causing them to fall backwards and hit their head. (Continued on LIC9099-C) A review of facility records revealed R1 had a stroke on February 19, 2011, which resulted in a weak left leg. It was also documented that their primary diagnosis was gait instability. R1 had over six unwitnessed falls from August 13, 2019 through February 4, 2020. On February 4, 2020, R1 was admitted to the hospital with a diagnosis of subdural hematoma. Outside agency notes dated February 8, 2020, show that R1 advised hospital staff they had also fallen two other times in the previous week; and both times they fell in the bathroom and hit their head in the same place. Despite the facility documenting all R1’s previous falls and reassessments, no measures were put in place to mitigate future falls or increase supervision. A review of the plan of care dated February 2, 2020, revealed a history of falls but there were no documented objectives to mitigate falls other than reminding resident to call for assistance when transferring. Based upon interviews conducted and records review, the above allegation is substantiated. This finding means that the preponderance of the evidence standard has been met and the allegation is valid. Deficiency is cited in accordance with California Code of Regulations, Title 22. Due to the serious nature of the allegations, the Department will review this case for a Civil Penalty per Health and Safety Code section 1569.49(f). An exit interview was conducted with Wesley Lavender and a copy of this report and Licensee/Appeal Rights (LIC 9058) were provided to Wesley Lavender whose signature below confirms receipt of documents.