Complaint·April 7, 2026

and no diagnosis of dementia or mild cognitive impairment. All other residents in the facility have dementia or mild cognitive impairment. Interviews conducted revealed staff observed Resident 1 (R1) demonstrate inappropriate behavior towards other residents. Staff stated R1 was observed trying to go into other residents’ rooms and described R1’s behavior as “predatory”. Interviews conducted revealed R1 was observed with their hand between Resident 2’s (R2’s) legs and R1 “backed off” when R2 became combative towards R1. Interviews conducted revealed R1 was found “multiple times” with their hand on Resident 3’s (R3’s) breasts. Interviews conducted revealed Resident 4 (R4) demonstrated a different demeanor in R1’s presence and appeared to be “uncomfortable” when R1 was near R4. Interviews conducted revealed staff reported R1’s behavior and specific incidents to Administrator Gerr. Administrator responded saying the interactions are most likely consensual, especially between R1 and R4, and noted residents have personal rights. Staff stated they felt R1 followed and pursued R4, and coerced R4. The investigation revealed Administrator did not provide support or guidance to the staff and instead deflected the incidents by saying R1 had “their needs”. Staff indicated they were never directed to provide additional supervision to R1 or R4, despite the Administrator being aware of R1’s behaviors. Additionally, text messages and interviews revealed staff found R4 in R5’s room, with R4’s pants pulled down and the covers off of R5. Interviews revealed R4 was touching R5’s briefs. R5 was saying they did not need assistance, believing R4 to be a staff. R4 was very confused when staff intervened. Based on interviews conducted and records reviewed, the allegation Staff did not protect resident from being inappropriately touched by another resident is deemed Substantiated at this time. On the allegation, Staff does not provide a safe environment for resident: Reporting Party voiced concern for a resident’s safety when staff reported to Administrator that R1 was demonstrating inappropriate behavior towards other residents. Interviews conducted revealed R1 was observed trying to enter other residents’ rooms and when R1 was “called out” on their behavior, R1 would “slink off” and go to their room. Interviews conducted revealed when R1 “was affectionate” towards residents in the dining room, and when R1 was told “No” by staff, R1 would then leave the area and go to their room. Records review and interviews conducted revealed R1 has a diagnosis of neuropathy and no diagnosis of dementia or mild cognitive impairment. All other residents in the facility have dementia or mild cognitive impairment. By R1 residing in the facility, R1 is in an environment that is not compatible with their mental cognition and diagnosis. On 4/16/2025, LPA Kontilis conducted a Case Management visit to the facility wherein a citation was issued against the facility as a violation for admitting a resident who did not have a dementia diagnosis and did not require the level of care provided by the facility. The facility is a secured Please continue to 9099-C, Pg 3. perimeter memory care facility, per regulation, all residents must have conservatorship to be in a secured perimeter memory care facility or a signed acknowledgment that they agree to be in a secured perimeter facility. Based on the information obtained over the course of the investigation, R1 residing in a locked memory care facility with no dementia or mild cognitive impairment diagnosis and is/was residing in a facility that is not compatible with other residents in care, presents an unsafe and vulnerable environment detrimental to all residents including R1. Therefore, the allegation that Staff does not provide a safe environment for a resident is deemed Substantiated at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted. Copy of report issued. Appeal Rights issued.