complaint·February 26, 2026

(Cont. from LIC-9099) On the evening of August 26th, 2024, R1 was found lying next to R2 in R2s single bed. Interviews conducted with witnesses, S2 reported that S2 walked in on R2 and R1 without their briefs on, lying next to each other. S2 called caregiver, S1 for assistance. Staff, S1, S2, S3 revealed that R2 did not have the capacity to remove his/her own briefs, therefore, suspecting that it was R1 that removed it. However, other staff (S4 & S5) reported that R2 had a history of randomly removing his/her own briefs. S1 & S2 denied they saw something happened between the residents. S1 and S2 reported the incident to the lead staff, S4. Interviews with S1, S2 and S4 confirmed that R1 was removed from sharing the same room with R2 to prevent another incident. All staff reported that R1 did not have a history of sexually assaulting R2 or other residents. Furthermore, all staff interviews reported that, specifically for R1 and R2, checking on them every 30 minutes to bihourly suffices as there were no history of sexual or suspicious activity between the two. R1 & R2 were also interviewed, and both could not recall the incident and could not provide relevant statements due to neurocognitive condition. Other residents R3 & R4 and both denied having experienced any sexual abuse from staff or residents. All residents reported feeling safe and did not express concerns about staff supervision. For the allegation of staff did not follow COVID-19 protocols, RP was alleging that staff were forced to come to work even though, they were positive. During the interviews, staff mentioned that any staff that tested positive is to isolate for 5 days or more depending on the symptoms. No staff was forced to work if they tested positive. S7 mentioned that agency caregivers were hired so that there is coverage in the facility. (Cont. on LIC-9099-C pg, 1) (Cont. from LIC 9099-C) Regarding the allegation of staff did not seek medical attention for resident (R3), RP stated that R3 reported he/she was not feeling well and asked to go to the hospital, Administrator told R3 a mobile doctor would be coming in to check, but that did not happen. Based on staff interviews, R3 did not request any transport to go to the hospital, nor any resident during this time. It was alleged that Staff did not keep the facility clean, RP stated that facility floors are often dirty, housekeeping and maintenance do not work on the weekends. Facility provided records showing that an outside agency is hired to keep the facility clean when there is no staff available. S6 stated that the facility is always kept clean. For the allegation of Staff did not keep facility equipment clean, RP stated that the water container was not cleaned regularly. Staff mentioned that kitchen staff regularly clean the equipment and puts fresh water every day. Regarding the allegation of Staff did not provide adequate food service, RP stated that food provided to residents was not in the menu. The food would sometimes change from what was on the menu. S6 stated that they try to stick as much as possible on the menu but if anything doesn't get delivered on time then they have to substitute. LPA reviewed the menu, and it showed a variety of dishes served. Also, annual visits done by the department show that the facility always has 2 days’ perishable and 7 days non-perishable food supply available. (Cont. on LIC-9099-C pg. 2) (Cont. from LIC 9099-C pg. 1) For the allegation of Staff mismanaged a resident's medication, RP stated that on multiple occasions medications was seen in R5s room. According to staff members, all medications are centrally stored. There are no medications in residents bedrooms, and no concerns of staff mismanaging residents medication. Based on interviews and records review, the department has determined that 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, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Administrator Susan Caccam, whose signature below confirms receipt of these rights.