Complaint·March 4, 2026

Due to lack of supervsion, resident engaged in sexual relations with another resident: On 11/17/2025, around 7:12PM, facility staff received a notice from surveillance video system that a fall in a resident room in memory care unit. Facility staff went to the resident room to check and found resident R1 and R2 were undressed from the waist down. R1 was on the floor and was assisted by staff to get off the floor. R1 and R2 were assessed and both were found without injuries and were not under distress. Staff S1 reviewed the camera footage, the video showed that R2 and R1 potentially engaged in intercourse. Both residents R1 and R2 were then separated and put into their respective apartments. On 11/19/2025, the Department received the incident report from the facility. LPA called the facility and interviewed previous Wellness Director (PWD). R1 and R2 do not recall what happened. R1 and R2's families, police, and LTCO were notified. PWD stated, this was the first time that both R1 and R2 have exhibited these behaviors. LPA requested R1 and R2's Physician Report, and Care Plans. On 12/23/2025, LPA interviewed Vice President of Wellness from corporate (VPW). VPW stated resident R1 went to resident R2's room, both R1 and R2 are memory caret residents. VPW stated staff responded to surveillance video system because R1 was found on the floor. VPW stated staff entered R2's room to check and found R1 and R2 were without underpants. R1 was on the floor. R1 and R2 were assessed and no injuries were found. R1 and R2 were not under distress. R1 was on R2's bed and had engaged in intercourse which led to R1's falling off the bed. The sex appeared to be consensual. R2 was unable to remember what happened. R1 denied any sexual abuse or coercion. The facility notified LTCO, police and CCL office. The facility notifies R1 and R2's families. Both families do not have any concern about the incident. LTCO and police came to the facility on 11/18/2025 to investigate. The facility did not receive any accusation from Police and LTCO. VPW stated R1 and R2 were observed talking to each other before several times. VPW stated R1 and R2 seems to be friends. VPW stated after the incident, R1 and R2 still talk to each other and nothing seems strange. VPW stated this is the only one case between R1 and R2. VPW stated R1 and R2 talk to each other very often on common area. VPW stated R1 did not went to any other rooms before and after the incident. LPA interviewed staff S1. S1 stated he/she received notice from surveillance video system for a resident fell on the floor and went to check resident R2's room and found R1 and R2 were naked from wrist to bottom. S1 stated from the camera footage, R1 and R2 had intercourse. S1 stated the sex appears to be consensual. Continue on LIC9099-C. Page 2 of 4. S1 stated on 11/17/25 after dinner, around 7:20PM, he/she was distributing medications to residents in memory care unit, and caregivers were helping residents to prepare to go to beds. S1 stated there were 4 caregivers on duty for memory care unit. S1 stated he/she did not see R1 entered R2's room. S1 stated there were no noise, no screaming, and no shouting at that time period. S1 stated R1 does not complain anything. S1 stated both families do not have any complaint and no concerns. S1 stated R1 and R2 are friends. Based on the interview and record reviewed, the facility notified the incident to LTCO, Police, CCL office, and families. The facility did not receive accusation for the incident. Staff do not enure residents laundry is done: On 12/23/2025, LPA interviewed Vice President of Wellness (VPW) from the corporate. VPW stated the facility provide laundry service once per week and as needed. VPW stated the laundry including resident's clothes, bed sheet, and linens. VPW stated if the residents need more laundry service they can notify the facility. VPW stated the resident family needs to provide the laundry basket, and the resident's soiled clothes can be put in. VPW stated the facility has scheduled laundry for residents. VPW stated caregivers conduct the laundry and will put the clean clothes back to resident room and fold them into closet. VPW provided the copy of the laundry schedule. LPA toured 11 resident rooms with VPW, LPA did not see soiled clothes piled in the resident rooms. VPW stated caregivers can help to put the soiled clothes in basket, but only when caregivers enter the resident room. LPA interviewed 6 residents. 6 Out of 6 residents did not complain the facility laundry service. On 01/06/2026, LPA interviewed Operational Specialist (OS) from corporate. OS stated memory care unit residents have 2 laundries per week and assisted living unit residents have a laundry per week. OS stated each resident room has closets to put resident's clothes, bedding and linens. OS stated residents can bring their furniture in their rooms OS stated usually the closet space is big enough for resident to put their clothes and bedding/linen. OS stated some residents bring their cabinet/furniture to place their extra clothes and linens. Continur on LIC9099-C. Page 3 of 4. LPA toured all the 34 bedrooms in memory care unit with OS and Maintenance Director (MD). LPA did not observe any resident laundry basket with "overflow" soiled clothes. LPA did not observe resident room was unorganized or messed up with soiled clothes. LPA observed room #201 with clean and organized linens piled on a sofa. LPA checked resident rooms' closet and cabinet with OS, and found some closets/cabinets of resident rooms were full. OS explained if resident has too many clothes and linens for caregiver to put in closet and cabinet, they can bring their own closet or furniture. LPA observed some rooms having blankets on the chair or sofa which are believed that residents used them when they sat or slept on chair/sofa before, and residents left the blanks there on purpose. The Department has investigated the above allegations. Based on the investigation, records reviewed, and interviews conducted, the Department found that the above allegation is UNFOUNDED , meaning that the allegation is false, could not have happened and/or is without a reasonable basis. No citations noted at today’s compliant investigation visit. Exit interview was conducted with RCS. This report was provided to review and for signature. A copy of this report was provided to RCS. Page 4 of 4.