complaint·September 30, 2025

On January 7, 2025, the Department interviewed 3 staff (S1-S3). 3 out of 3 staff (S1-S3) stated they have not seen or heard of resident R2 emotionally or sexually abusing resident R1. 3 out of 3 staff (S1-S3) stated the facility staff will observe R1 and R2 in the common areas, such as the front lobby or dining room and they have not seen the residents upset or have concerns about abuse. 3 out of 3 staff (S1-S3) stated R1 is supervised 24 hours/7 days a week with a 1:1 companion in addition to facility staff conducting safety checks. 3 out of 3 staff (S1-S3) stated R1 has not brought up any concerns to facility staff. S2 stated they personally asked R1 if R2 has been emotional and/or sexually abusing the resident and R1 has refused the allegations. LPA Rai interviewed Administrator (ADM) Bradley Burgoyne. ADM stated R1 and R2 are friends and spend time with each other. ADM stated R1 is capable of making his/her own decisions and wants to hand out with R2. ADM stated R1 has a 1 on 1 care giver, so any instances where they come into contact would be supervised. On 8/22/2025, LPA Rai interviewed R1. R1 stated the emotional and sexual abuse allegations are false. R1 stated he/she feels safe in the community. R1 stated staff and residents, including R2, are not emotional or sexually abusing him/her. R1 stated he/she does not know how the allegations are true when R1 is fond of R2 and feels safe with R2. On September 12 and 23, 2025, LPA Monter interviewed residents R1-R8. 5 Out of 8 residents, (R1, R4, R5, R6, R7) stated they haven’t seen or heard residents speaking to each other in a negative or inappropriate way. R2 stated he/she hasn’t heard any inappropriate comments being made to other residents. R2 stated he/she has heard residents making mean comments, like saying “here comes trouble.” R2 stated in response he/she will make a mean comment back, regarding his/her weight. R3 stated R2 will make inappropriate comments to R3, but in response, R3 will make inappropriate comments to R2. R8 stated he/she hasn’t heard any inappropriate comments from residents or resident R2. R8 stated he/she heard that R2 was bossing around R1, but he/she didn’t witness this event. Page 2 Out of 3. 5 Out of 8 residents interviewed, (R1, R4, R5, R6, R7) stated they haven’t seen or heard residents touching other residents in an inappropriate manner. R2 stated he/she doesn’t touch other residents without their consent. R2 stated he/she hasn’t seen other residents who touch others in inappropriate manner. R3 stated he/she hasn’t personally seen R2 put arms around a resident/ touching resident, making them feel uncomfortable. R3 stated he/she has heard about this from other residents. R8 stated in terms of the inappropriateness, R2 will sometimes put his/her arm around you. On September 12 and 23, 2025, LPA Monter interviewed staff S4-S10. 7 Out of 7 Staff interviewed stated they haven’t seen residents speaking or touching other residents in an inappropriate manner. Based on review of R1 and R2’s facility file, there are zero incidents reported regarding R1 and R2 being involved in sexual/emotional/physical abuse. Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Director of Health Services Adriana Delao and a copy of the report was provided.