Incident investigation·May 20, 2025

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct a case management – incident visit. LPA met with Executive Director, Tina Bagheri. This visit is a follow-up on a case management visit conducted on 11/08/2024 regarding sexual abuse by staff (S1) to resident (R1) the night of 11/06/2024. On 11/07/2024, the incident was reported to the Department. During the investigation, it was found that S1 had inappropriately touched R1’s private areas without consent. The incident was witnessed by a staff member who entered the memory care unit and observed the incident. This staff member immediately rushed to grab another staff and returned to the memory care unit where R1 motioned for the two staff to come over. Due to R1’s diagnosis, R1 primarily relied on physical gesture to communicate. R1 was motioning a grabbing motion in R1’s private areas indicating that R1 was inappropriately touched by S1. Law enforcement investigated the case and interviewed R1 who was able to articulate that an incident had occurred based on expression. R1 answered yes to the questions of S1 touching R1’s private areas, if he/she was scared, if he/she requested help, if S1 hit him/her, if S1 took his/her pants off, and if R1 saw S1’s private part. R1 was noticeablely distraught during the interview. Page 1 of 2. R1 had a surveillance camera inside his/her room that was set up by R1’s power of attorney (POA). The surveillance camera from R1’s room showed unusual behavior from S1 the night of the incident. Although R1 and S1 were off camera for part of the surveillance footage clips, R1 could be heard yelling for help. The surveillance footage corroborated with the two staff member/witness statements, when they explained that R1 tried to hand signal being inappropriately touched by S1. On 11/07/2024, S1 was immediately terminated from the facility. On 11/12/2024, S1 was immediately excluded from the Department. A case management visit was conducted at the facility and hand delivered S1’s order for immediate exclusion. On 11/14/2024, S1 was arrested and transported to jail without incident, where S1 remains without bail. A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Executive Director, Tina Bagheri and a copy of the report and appeal rights were provided. Page 2 of 2.