Incident investigation·July 20, 2022

On 7/20/22 at 11:55 am, Licensing Program Analyst (LPA) Darlene Chavez conducted a Case Management - Incident visit to issue final findings and citations related to the Case Management visit conducted on 05/11/2022. LPA met with Rachelle Tellez, Assistant Administrator, and Leah Figaro, Human Resources Manager, and explained the purpose of the visit. On 5/11/22, from 2:37pm to 4:00pm, Licensing Program Analyst (LPA) Darlene Chavez conducted an unannounced case management visit to the facility. LPA met with Jessica Bailey, Administrator, and explained the reason for the visit. On 5/11/22, Administrator faxed an incident report (LIC 624) and Report of Suspected Dependent Adult/Elder Abuse (SOC 341) to Community Care Licensing (CCL) stating that, on 5/10/22, Staff #1 (S1) witnessed Resident #1 (R1) being sexually abused by Staff #2 (S2) in R1’s room. LPA interviewed the Administrator and obtained documentation pertinent to the investigation. LPA determined further investigation was needed. On 05/11/22, this case was referred to the CCL Investigations Branch (IB) and assigned to Investigator Elisia Rippe. Investigator Rippe contacted the San Luis Obispo Police Department (SLO PD) from 05/16/2022 to 06/06/2022 regarding the status of the investigation and to schedule joint interviews with witnesses. On 06/07/2022, at 10:30am and 11:37am, Investigator Rippe and SLO PD Detective Chris Chitty conducted interviews with the Administrator; at 10:47am and 11:20am, with R1’s representative; at 10:56am with R1; and at 11:46am, with S1. In addition, Investigator Rippe also reviewed Long Term Care Ombudsman (LTCO) reports and facility file documents related to R1. Continued on 809-D. On 05/10/2022, at approximately 9:00am, S1 went into R1’s room and observed S2 hovering over R1 with R1’s shirt pulled up and kissing R1’s breast. R1 stated they told S2 they did not want S2 to touch R1. The facility personnel asked S2 to leave the resident’s room. S2 attempted to visit R1’s room again. Facility personnel then escorted S2 out of the facility and contacted SLO PD law enforcement. S2’s employment with the facility was terminated effective 05/10/2022. On 05/11/2022, the facility self-reported that R1 disclosed that they were inappropriately touched by S2. The outcome of the SLO PD investigation is currently pending. Based on the information obtained through the LTCO report and joint interviews conducted with SLO PD, Investigator Rippe determined there was sufficient evidence to support a substantiated finding. Therefore, the allegation “Sexual Abuse – Facility Staff #2 (S2) inappropriately touched facility Resident #1 (R1)” is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 809-D). Exit interview conducted, appeal rights provided, a copy of this report issued.