Incident investigation·September 22, 2023

Licensing Program Analyst (LPA) Dulek conducted a subsequent case management visit to deliver findings for the above allegation. LPA met with Kailey Vanderwall and explained the reason for the visit. On 05/11/2023, from 8:48am to 10:25am, Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced Case Management – Incident visit for the purpose of following up on a self-reported incident that occurred on 05/08/2023. LPA Dulek initially met with Business Office Director Kailey Vanderwall. The Executive Director (ED) Bradlee Foerschner arrived at 9:00am and the LPA explained the reason for the visit. On 05/08/2023 at 04:10pm, LPA Dulek received a telephone call from the ED indicating Resident #1 (R1) who resides in the memory care unit, had made an allegation of abuse against Staff #1 (S1). The LPA requested that an incident report and suspected abuse report be sent to the Woodland Hills Regional Office. The written report was faxed and received on 05/09/2023. Additionally, the ED informed the LPA that notifications were made to R1's resident representative, primary care physician, the local police department, and the Long-Term Care Ombudsman (LTCO). During the visit, the LPA along with the Business Office Director toured the facility at 8:51am, interviewed the ED at 9:04am, and obtained copies of pertinent documents. No immediate health and safety hazards were identified during the visit. The ED was informed that Investigator Ryan Miles from CCLD's Investigations Branch would follow up regarding the incident. On 06/03/2023, at approximately 2:01pm, Investigator Miles conducted an interview with the Director of Memory Care; on 06/04/2023, at approximately 1:40pm, with R1; and on 07/05/2023, from approximately 10:54am to 11:18am, with S1 and the ED. In addition, the investigator reviewed facility file documents related to R1 and S1, and obtained and reviewed the Ventura County Sheriff’s Department (VCSD) Report #2023-58367. The investigation revealed that on 05/08/2023, R1 reported to the Director of Memory Care that S1 inappropriately touched them. R1 stated “a couple of weeks ago” S1 penetrated their vagina with S1’s finger when S1 came to R1’s room to provide personal care. The ED also interviewed R1. Throughout the interview the timeline changed of when the alleged incident occurred ranging from 2 days to a few weeks ago. Report Continued on LIC 809-C During the interview with the ED, R1 stated “there was construction being done in R1’s room, with white chalk on the ground caused by the construction, and the bathroom walls have been moved”. The ED notified R1’s physician of the allegation and delusions. R1’s physician conducted an examination of R1 and found no physical signs of a sexual assault. When interviewed by the police, R1 stated the incident happened a few months ago; and did not recall being inappropriately touched by S1 when interviewed by Investigator Miles. S1 denied touching R1 inappropriately. S1 was placed on administrative leave during the facility internal investigation. S1 was allowed to return to work on 05/10/2023. A review of R1’s physician report, signed on 07/26/2022, lists the primary diagnosis as altered mental status: Dementia. Other conditions listed included confused/disoriented, and sundowning behavior. Additional information obtained from interviews and medical reports revealed that R1 also suffered from delusional thoughts and hallucinations at times. According to the supporting documents, when R1 resided at a Skilled Nursing Facility in July 2022, the notes documented on 07/06/2022 to “monitor R1’s hallucinations such as sexual contact with roommate or staff”. R1’s resident representative also confirmed R1 experienced “delusions involving sexual allegations”. According to the VCSD report, Deputy Turner contacted R1 to ask a few questions to assist in assessing R1’s cognitive ability and comprehension. During the initial questioning and duration of the conversation, R1 “expressed observable cognitive impairment”. Based on R1’s cognitive mental status it was determined that R1 would not be able to provide additional accurate information. S1 was contacted and denied the allegation. The report concluded that the VCSD was unable to determine a crime occurred and the case was closed. Based on the interviews conducted and supporting documents, the Department does not have sufficient evidence to support the allegation of sexual abuse. Therefore, the allegation “Sexual Abuse – Resident allegedly was inappropriately touched by a staff member” is deemed Unsubstantiated at this time. Exit interview conducted. A copy of report of the report was provided.