Follow-up on corrections·September 8, 2025

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced case management visit. LPA identified herself to, was greeted by, and explained the purpose of the visit to Administrator John "Stuart" Neave. On 7/9/2024, the Department received a self-reported incident report and report of suspected dependent adult/elder abuse (SOC341) from the facility that described the alleged incident where Staff 1 (S1) touched Resident 1 (R1) genitals. On 7/10/2024, the Department conducted a case management visit to conduct a health and safety visit and interviewed staff and residents. Review of R1’s assessment documents dated July 2023 revealed that R1 had a diagnosis of major neurocognitive disease, had short term memory loss, and required assistance with bathing, grooming, dressing, and toileting. Interviews with facility staff revealed that on 6/26/2024, staff overheard R1 tell another resident at the facility that S1 kissed R1’s face and touched R1’s genitals. When interviewed by the Department, R1 stated that S1 wanted a sexual relationship with R1 and had touched R1’s genitals while S1 showered R1. While R1 remained consistent in the accusation against S1 across multiple interviews, R1 was confused, disoriented to time, and unable to provide specific details regarding the incident, including if the incident had occurred multiple times. During R1’s multiple description of the incident, R1 provided details that did not make sense or contradicted R1’s previous descriptions of the incident. Interviews with staff, including S1, revealed that S1 was responsible for providing showers for residents, including R1. Interviews with other residents denied any issues with staff interactions and stated staff were pleasant, however, a resident had observed S1 kiss a resident on the cheek, which was supported by staff interviews. Continued on LIC809-C page... Staff denied being aware of any resident complaints regarding their interactions with S1. During interviews, S1 denied the allegation of inappropriate touching, either during bathing or otherwise. The evidence obtained during Department’s investigation did not meet the preponderance of evidence for a violation of regulations regarding the incident between R1 and S1. Interviews with facility staff revealed that staff did not report R1’s statements to facility management or any other agencies or other individuals, which interviews with facility management confirmed. Interviews with staff and facility management revealed that facility management became aware of the incident when R1 spoke to one of the Administrators on 6/28/2024. Review of incident reports and SOC341 submitted to the Department by the facility revealed that the incident was reported to the Department on 7/9/2024, eleven (11) days after facility management was made aware of the incident, and thirteen (13) days after staff became aware of the incident. Therefore, following deficiency was cited for reporting requirements and noted on the attached LIC809-D page. An exit interview was conducted with Administrator John "Stuart" Neave , whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).