Incident investigation·May 5, 2026

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced Case Management visit to follow up on an incident reported to Community Care Licensing (CCL). LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Executive Director Mercedes Margritz and Business Office Manager Emerald Jordan. Community Care Licensing received a SOC 341 report from an outside source on 4/29/26 in which it was reported that a resident (Identified as R1) had been admitted to the hospital for rectal bleeding. Per the report, R1 had reported the bleeding was caused by having consensual sex with another resident at the facility. During the encounter, R1 then indicated they wished to stop and the other resident did not stop until the second time R1 had asked. R1 is diagnosed with Dementia. During today's visit, LPA conducted file review and interviews, and provided consultation with Executive Director Margritz. Law enforcement had been contacted regarding the incident and per their investigation, R1's statement of event dates and details would rapidly change and they would name different residents at the facility or mix names of multiple residents. Additionally, per review of R1's records and interviews with staff, R1 has had ongoing rectal bleeding for a span of several weeks. R1's records indicate a history of a medical condition that causes rectal bleeding. On 4/15/26, R1's responsible party had brought up to facility staff that R1 shared to to them that R1 had a consensual sexual encounter with another resident which turned into anal penetration and resulted in rectal bleeding. [Continued on LIC 809-C] [Continued from LIC 809] During another episode of rectal bleeding on 4/29/26, R1's responsible party then took R1 to the hospital to be evaluated. R1 returned the next day with new medication orders for pain management. Based on interviews and file review, the facility had been made aware of R1's sexual encounter on 4/15/26 and CCL had not received any notification of the incident within the required seven (7) days. A Type B deficiency for not meeting reporting requirements was issued, and details are included on the attached LIC 809-D page. Interviews with staff indicated the facility had implemented increased routine checks on R1 since their return from the hospital. LPA attempted to interview R1 during their visit, however R1 was being assisted with showering. One deficiency was cited during today's visit. An exit interview was conducted with Executive Director Margritz to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.