complaint·November 17, 2025

(Continued from LIC9099 2 of 3) Staff interviews revealed that Resident 1 (R1) was touched inappropriately by Resident 3 (R3) when R3 wandered into R1’s room. R1 was fully clothed at the time and was able to instruct R3 to leave. R3 complied and exited the room. R1 immediately reported the incident to facility staff. Staff also reported that Resident 2 (R2) was asleep in their room when R3 entered and inappropriately touched R2 while R2 was fully clothed. R2 instructed R3 to leave the room, and R3 complied. R2 also immediately reported the incident to staff. Resident interview revealed R1 stated they were in their room when R3 entered without permission. R1 reported that R3 approached them and touched them inappropriately over their clothing. R1 stated they immediately told R3 to leave the room. R3 complied and exited. R1 reported feeling uncomfortable and informed staff of the incident right away. R1 stated they did not sustain any physical injuries but were upset by the incident and requested that R3 not be allowed to enter their room again. R2 stated they were asleep in their room when they awoke to find R3 in the room. R2 reported that R3 touched them inappropriately over their clothing. R2 stated they told R3 to leave, and R3 exited the room without further incident. R2 reported the incident to staff immediately. R2 expressed concern about safety and requested that staff ensure R3 does not enter their room again. Records review revealed R3 does not have a documented history of wandering behaviors or inappropriate behaviors. The wandering and inappropriate behavior was identified by staff and R3 was sent to the hospital for evaluation. Incident Reports dated 4/1/25 document the two separate incidents involving R3 entering the rooms of R1 and R2 and making inappropriate physical contact. Both reports (SOC341) were completed by staff and submitted to the Community Care Licensing and the Ombudsman office. There was documentation of immediate protective measures taken to prevent recurrence, such as increased monitoring and hospitalization for evaluation. (Continued from LIC9099C 3 of 3) Staff Communication Logs and Shift Notes from the dates of the incidents reflect proactive interventions. Based on relevant interviews and records review, the preponderance of evidence has been met that alleged violation occurred and are therefore substantiated.  Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D).  A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Natalie Carlborg, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.