Incident investigation·December 7, 2023

Licensing Program Analyst (LPA) Renee Campbell conducted an unannounced Case Management visit on this date and met with Assistant Executive Director (AED) Lakhbir Kaur. The Case Management visit pertains to an alleged sexual assault that the family self-reported. During the visit, LPA Campbell collected documents and attempted to conduct interviews that were pertinent to the incident report. LPA Campbell reviewed R1’s Physician’s report and R1’s Admission Agreement policy regarding Sexual Behaviors. When LPA Campbell attempted to speak to R1, the resident stated they “did not wish to talk about it”. LPA Campbell then attempted to call R1’s emergency contact and was able to interview them. The personnel file for S1 was reviewed and documentation of S1’s suspension was observed. As part of the investigation into the incident, the AED attempted to view camera footage and interview residents to identify further incidents of alleged abuse. Per licensing regulations, licensing and emergency contacts were notified and an SOC 341 was submitted to the Ombudsman office. The police were contacted, and a copy of the police report requested. The facility investigation is ongoing while staff work to guard R1’s privacy and avoid upsetting current residents. Per the AED, there is no facility protocol regarding unwanted sexual advances. LPA Campbell suggested adding such information to the admission agreement. At this time, the facility will provide the police report, 602, employee suspension letter and the sexual behavior page from the admission agreement. Later, the facility will provide further in-service training and protocols addressing unwanted sexual advances. No deficiencies were issued during the visit. Exit interview conducted with Lakhbir Kaur, AED and a copy of this report was provided.