Complaint·May 29, 2025

On 01/14/2025 (Tuesday) or 01/15/2025 (Wednesday) at approximately 2215 hours, R1 reported that S1 grabbed him/her by the neck, took off his/her clothes, touched him/her in private areas while S2 stood and watched. R1 stated that S1 and S2 were going to give him/her a shower when the incident occurred. However, according to staff and R1’s shower schedule, R1 is assisted with showers on Monday and Friday between 1500 – 1600 hours. Law enforcement conducted an investigation and interviewed R1 and S1. It was noted that R1 did not recognize or know the names of the staff who were part of the incident. S1 denied the allegations. S1 states that there was an incident where S1 and S2 checked on R1 in his/her room and found R1 laying too close to the edge of his/her bed. S1 and S2 tried to help R1 back up to his/her bed, but R1 become irritated and aggressive. S1 and S2 decided to leave R1’s room and stated nothing else happened. Based on review of the law enforcement records, R1 did not have any visible injuries and declined a Sexual Assault Forensic Exam (SAFE). No arrests were made by law enforcement. R1 was interviewed. Based on interview with R1, it was stated that S1 and S2 came into his/her room to give him/her a shower. R1 states that S1 yelled at him/her, grabbed his/her neck, and laid on top of him/her. R1 stated that S1 touched him/her all over his/her body included the chest and arm area. R1 stated the touching occurred over clothes and a blanket. R1 states that S1 did not touch his/her private part and only touched his/her lower body. R1 stated to have kneed S1 and both staff left the room. S1 and S2 were interviewed. Based on staff interviews, both staff denied the allegations of inappropriately touching and handling R1. S1 and S2 states that they went to R1’s room to check on his/her diaper and found R1 laying on the edge of the bed. S1 and S2 tried to move R1 back to the middle of the bed when R1 became upset and refused assistance. S1 states that that he/she may have touched R1 when trying to move him/her but not in an inappropriate area like the private areas. Page 2 of 4. S2 denied the observation of S1 touching R1 inappropriately, and states that S1 only touched the back of R1’s shoulder while they were trying to prevent R1 from slipping off the bed. It was stated that S1 was wearing a blanket while being moved. S2 states that R1 was upset with S1 because S1’s voice was too loud. S1 and S2 never mentioned any other incidents occurring to include pushing R1 and inappropriately restraining R1 in bed. S1 and S2 stated they had only assisted R1 by moving R1 back to the middle of the bed to prevent R1 from falling. Due to R1 becoming upset and refusing assistance, S1 and S2 left the room and were not able to change R1’s diaper. S1 and S2 stated they never mentioned anything to R1 about a shower. S1 states that he/she never gave R1 a shower because R1 prefers to be assisted by the same gender staff. Based on staff interviews, it was stated that R1 has made similar allegations at another facility. It was also stated that R1 previously reported that he/she saw male staff in his/her room during the nocturnal shift, but only female staff worked during that shift. Staff members interviewed described S1 as a good worker and good with the residents. Staff never observed any inappropriate behaviors from S1 towards the residents nor has there been any previous complaints against S1 acting inappropriately towards the residents. To avoid any further issues with R1, S1 was instructed not to go to R1’s room going forward. It was alleged that staff allowed a resident (R1) to be soiled while in care as R1 was left in his/her own feces in bed. The length of time R1 was left in his/her own feces was unknown. 6 residents were interviewed. Based on resident interview, 5 out of 6 residents stated that they have never been left soiled for an extended period of time. 1 out of 5 residents stated that he/she was left soiled for 4 hours but was unable to recall more information as to when and what time it occurred. Page 3 of 4. Based on interview with R1, R1 denied ever being left soiled while in care of the facility. 4 staff members were interviewed. Based on staff interview, it was stated that staff check on the residents and change their undergarments as needed or as often as 1-2 hours to ensure the residents are kept dry and comfortable. 4 out of 4 staff denied the observation of a resident who was left soiled for an extended period of time. 4 out of 4 staff denied the observation of R1 left soiled. 4 out of 4 staff states that they will always assist residents if they know and observe that they are soiled. It was alleged that staff do not ensure resident (R1)’s toilet is being flushed. 6 residents were interviewed. Based on resident interview, it was stated that if the resident is able toilet on their own, then the resident would flush their own toilet. Based on interview with R1, R1 states that he/she is capable of using the toilet on his/her own and flushes his/her own toilet after use. Another resident (R2) stated that sometimes the resident or staff would forget to the flush the toilet after use, however, if it’s brought to the staff or resident’s attention the toilet would get flushed. On 05/29/2025, LPA interviewed 6 residents inside their apartments. 5 out of 6 of the resident’s toilets were observed flushed. 1 out of 6 residents toilets was not flushed and contained urine and toilet paper, however this resident is independent with toileting. No foul orders observed. 4 staff members were interviewed. Based on staff interview, R1 usually flushes his/her own toilet. 4 out of 4 staff members stated that if staff were to observe that a resident’s toilet is not flushed, then staff would assist in flushing the toilet. The Department has investigated the above allegations. Based on interview, record review and observation the above allegations are unsubstantiated. An unsubstantiated finding indicates that although the allegations may have happened and/or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Kippie Castronovo and a copy of the report was provided. Page 4 of 4.