Incident investigation·December 11, 2025

Licensing Program Analyst (LPA) Maria (Mita) Partoza, conducted an unannounced case management visit regarding the incident that happened between two resident. LPA met with designated administrator Ninfa Gozon and stated the purpose of the visit. On 10/22/2025, the Department received an incident report regarding intimacy between two residents. On 10/23/25 and 11/05/25 the Department conducted an investigation and interviewed R1 and R2, 2 staff and the administrator. Based on interview, the facility staff was not aware that R1 went to R2s room without invitation from R2 at approximately 0200 hrs. R1 is high functioning, and can communicate and express his/her thought and gave his/her account of what happened. R2 is developmentally challenged, and cannot fully express himself/herself. R2 gave an unclear account if the intimacy was consensual or forced. Based on observation and document review, R1 is high functioning and is able to verbalize and communicate clearly. R2 is developmentally challenged and is not able to articulate and give detailed account of the foregoing event. Based on interview of staff 2 (S2) and administrator (ADM) both stated that R1 is high functioning. R2 is less verbal and has a hard time communicating and verbalizing and is not able to give account of the foregoing event. page 1 of 2 Based on observation and interview, staff 1 (S1) admitted that he/she was not aware that R1 went to R2s room and had intimacy in R1s room. S1 stated that he/she was busy watching on his/her tablet and have no line of sight of the hallways from the kitchen. S1 stated that most residents were asleep in the wee hours of the morning. The kitchen was closed and his/her line of sight was obstructed. S1 stated he/she did not hear R1 and R2 walking. S1 stated that he/she is the nocturnal (NOC) shift staff and supervises residents ensuring that they are asleep and not walking around disturbing other residents. Based on observations, interviews and document reviews. S1 did not provide care and supervision as identified in the client's needs and services plan as necessary to meet the client's needs. R2 requires care and supervision due to his/her her developmental capability and level of understanding. R1 stated he/she tiptoed to R2s room. R1 stated he/she knows that he/she is not allowed to go to the opposite gender's room without proper consent. S1 stated, he/she did not hear and see R1 and R2 walking because he/she was inside the kitchen with obstructed view of the open living area and dining area at approximately 0200 hrs. Therefore the preponderance of evidence that there is neglect and lack of supervision is substantiated. Deficiencies were cited during today's visit based on California Code of Regulations (CCR) Title 22, 85065.6 night supervision . See LIC 809D. An exit interview was conducted with designated administrator Ninfa Gozon. A copy of the report and appeals rights were provided. end of report page 2 of 2