complaint·April 18, 2024

Investigator Real conducted interviews on 09/21/2023, from approximately 11:30 a.m. to 2:30 p.m., with the Business Office Director and residents; and on 10/24/2023 with staff. Additionally, investigator Real reviewed facility file documents related to R1 and R2, and contacted the Oxnard Police Department who did not investigate the matter after it was determined no crime occurred and no police report was generated. A review of R1’s physician report, dated 10/28/2021, indicates a primary diagnosis of dementia, psychosis, and hypertension. Mental conditions are listed as confused, disoriented delusions at times. R1 needs stand-by assistance with all activities of daily living. A review of R2’s physician report, dated 06/14/2021, indicates a primary diagnosis of Parkinson’s disease. No dementia or mild cognitive impairment was noted. R2 has the capacity for all self-care needs and is able to store and administer their own medications. On 03/06/2020, R1 and R2 were admitted to the assisted living section of the facility. On 11/30/2022, when R1’s needs changed, R1 was admitted to the memory care section of the facility. The investigation revealed that R1 and R2 have been married for 53 years. R2 has dinner with R1 in the memory care section of the facility every night and after dinner they go back to R1’s room where they spend time together until R1 goes to bed. According to the Business Office Director, they witnessed R1 and R2 together in bed sometime in June 2023. Sometime between 6:00 p.m. and 6:30 p.m., a staff requested the director to meet them at R1’s room. Through the door they could hear R1 talking with R2 and heard R1 say “I’m not comfortable”. The director was not sure of the context of the statement, so they entered the room and observed R1 and R2 in bed and covered with a sheet. The director asked R1 if they were okay and R1 responded “yes, I’m okay.” The director did not observe any cuts or injuries on R1’s arms or anywhere else on R1’s body. R1 did not have any concerns with R2 being in the room and wanted R2 to remain with R1 in the room. R1 did not report any problems or concerns to the director and wanted them to leave. R2 also asked them to leave, the director and the staff then left after determining nothing was wrong. The resident care notes dated 06/21/2023 and 06/22/2023, document that R1 and R2’s resident representative was contacted to discuss intimacy, safety and privacy. R1 and R2’s resident representative was supportive of R1 and R2 being together alone in R1’s room and had no concerns. The resident care notes further document that on 06/13/2023, R1 was noted to have a skin tear to lower left arm and treated by staff. Home health services was contacted and redressed the wound on 06/16/2023. (Continue to LIC 9099c.) The interviews conducted with R1, R2, other residents and staff during the complaint investigation did not indicate R1 suffered any physical or sexual abuse from R2. R1 and R2 denied the allegation. R1 and R2’s resident representative was supportive of R1 and R2 being together alone in R1’s room and had no concerns. The residents interviewed felt safe in the facility and had no complaints or problems to report. No one reported any neglect or lack of care or supervision. The facility staff denied the allegation and felt the level of care provided to the residents was appropriate. The information and evidence obtained did not sufficiently support the allegation, therefore the allegation “Neglect/Lack of Supervision: Facility staff failed to provide an appropriate level of supervision which resulted in Resident #1 (R1) being sexually and physically assaulted by Resident #2 (R2)” is deemed Unsubstantiated at this time. Exit interview conducted, copy of this report issued.