Incident investigation·May 9, 2024

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a Case Management and was greeted by Morgan Holien, Administrator. On 5/8/2024 CCL received from facility a SOC341 report of abuse, type of abuse reported is physical abuse. Suspected abuser is unknown. On 5/1/ 2024, resident (R1) reported to Health and Wellness Director (HWD) that they were touched under the covers while sleeping. R1 reported that the suspect entered their room, and was touching them under the covers, making them feel uncomfortable. R1 stated they did not know the abuser but thinks the abuser delivers things to their room. R1 reported to HWD that it was not one of the current employees, that they know of, because the current employees do not match the physical description of the suspected abuser. R1 was upset and crying to HWD as they reported the abuse, but claimed the abuser did not sexually assault them. HWD immediately notified Santa Rosa Police Department by calling 911 to report the incident (Event #SR241220238). HWD also reported incident to LTCO. Per LPA interview with Admin, after HWD called 911 they then notified Admin of R1's report of abuse. While meeting with Admin, HWD received an email from R1's family member. Upon calling R1's family member, HWD was informed that R1 had told the family member that R1 had reported the incident to HWD. R1's family member refused to have the police come out. The police then contacted R1 on 5/2/2024 by telephone to conduct interview. Per Admin, R1 does not have a diagnosis of dementia or MCI, but does occasionally experience some issues with cognitive function. Per LPA interview with Admin, facility conducted an internal investigation on 5/1/2024 and 5/2/2024 with a subsequent follow up with staff on 5/6/2024. The facility's investigation yielded a finding of unsubstantiated. LPA confirmed with HWD R1 is now on frequent checks to monitor mental health and overall comfort. No deficiencies cited during this inspection.