complaint·January 23, 2026

Report Continued from LIC 9099... During the initial visit on 08/25/2025, between 2:25 p.m. and 3:50 p.m., LPA Arroyo conducted a physical plant tour with the Licensed Vocational Nurse (LVN) and requested and obtained copies of pertinent documents. On 10/14/2025, between 10:10 a.m. and 2:42 p.m., LPA Arroyo interviewed five staff and six residents. On 01/07/2026, between 09:45 a.m. and 1:30 p.m., LPA Arroyo observed residents in the common areas, conducted interviews with five staff members, conducted a resident file review, and obtained copies of pertinent documents. Additionally, during the course of the investigation, interviews with resident family members were conducted and police report was obtained. Records reviewed and interviews conducted revealed that R1 was admitted to the facility on 06/27/2023. According to R1’s physician’s report dated 02/26/2025, the primary diagnoses include Mild Cognitive Impairment (MCI), hypertension, and hyperlipidemia, with a secondary diagnosis of Chronic Kidney Disease stage 4 (CKD IV). The report indicated that R1 was not confused or disoriented and did not exhibit inappropriate, aggressive, wandering, or sundowning behaviors. It noted that R1 was able to follow instructions and communicate their needs. The report also described R1 as non-ambulatory and able to bathe, dress/groom, feed, and manage their own toileting needs. Additionally, R2 was admitted to the facility on 05/25/2023. Per the physician’s report dated 06/11/2024, R2 was also able to follow instructions and communicate their needs. R2’s primary diagnoses include dementia, Congestive Heart Failure (CHF), hypertension, Chronic Obstructive Pulmonary Disease (COPD), and depression. The report indicated that R2 was occasionally confused or disoriented and occasionally exhibited inappropriate, aggressive, wandering, or sundowning behaviors. It also described R2 as non-ambulatory and requiring assistance with Activities of Daily Living (ADLs), including bathing, dressing/grooming, feeding, and toileting. The investigation revealed that on 08/23/2025, R1 was sent to the hospital at the request of R1’s family. Although interviews indicated that R1 may have been experiencing bleeding, family members reported that R1 was taken to the hospital due to stomach problems which included pain and diarrhea. Report Continued on LIC 9099C... Report Continued from LIC 9099C... During the course of the investigation, it was further revealed that R1 and R2 spend much of their day sitting together in the main lobby and holding hands. Staff reported that they regularly check on both R1 and R2 throughout the day to ensure their well-being. R1 and R2 reside on the assisted living side of the facility and do not require continuous care; therefore, they are able to move freely throughout the facility. Staff stated that while they cannot prohibit R1 and R2 from seeing one another, boundaries have been established to ensure that the residents are not alone together in either resident’s room. Staff reported no concerns regarding R2 complying with staff instructions. Additionally, staff have encouraged R1 to participate in additional daily activities to help with engagement and reduce distractions. Additionally, while at the facility, the LPA observed R1 and R2 seated together in the main lobby as staff passed by every few minutes to monitor them. No issues or concerns were noted during these observations. During interviews, R1 denied being touched inappropriately by R2 at any time while residing at the facility. Both R1 and R2 separately stated that they enjoy spending time together. Furthermore, according to the Simi Valley Police Department report dated 08/23/2025, law enforcement indicated that R1 did not state at any point that they were a victim of a crime, and officers were unable to establish that a crime had occurred; therefore, the case was closed. Based on the information gathered during the course of the investigation, although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, allegation “Due to Staff Neglect / Lack of Supervision: Staff did not prevent resident in care from being sexually abused at the facility” is deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report was provided. Report Continued from LIC 9099... During the initial visit on 08/25/2025, between 2:25 p.m. and 3:50 p.m., LPA Arroyo conducted a physical plant tour with the Licensed Vocational Nurse (LVN) and requested and obtained copies of pertinent documents. On 10/14/2025, between 10:10 a.m. and 2:42 p.m., LPA Arroyo interviewed five staff and six residents. On 01/07/2026, between 09:45 a.m. and 1:30 p.m., LPA Arroyo observed residents in the common areas, conducted interviews with five (5) staff members, conducted a resident file review, and obtained copies of pertinent documents. Additionally, during the course of the investigation, interviews with resident family members were conducted. Records reviewed and interviews conducted revealed that R1 was admitted to the facility on 06/27/2023. According to R1’s physician’s report dated 02/26/2026, the primary diagnoses include Mild Cognitive Impairment (MCI), hypertension, and hyperlipidemia, with a secondary diagnosis of Chronic Kidney Disease stage 4 (CKD IV). The report indicated that R1 was not confused or disoriented and did not exhibit inappropriate, aggressive, wandering, or sundowning behaviors. It noted that R1 was able to follow instructions and communicate their needs. The report also described R1 as non-ambulatory and able to bathe, dress/groom, feed, and manage their own toileting needs. Additionally, R2 was admitted to the facility on 05/25/2023. Per the physician’s report dated 06/11/2024, R2 was also able to follow instructions and communicate their needs. R2’s primary diagnoses include dementia, Congestive Heart Failure (CHF), hypertension, Chronic Obstructive Pulmonary Disease (COPD), and depression. The report indicated that R2 was occasionally confused or disoriented and occasionally exhibited inappropriate, aggressive, wandering, or sundowning behaviors. It also described R2 as non-ambulatory and requiring assistance with Activities of Daily Living (ADLs), including bathing, dressing/grooming, feeding, and toileting. The investigation revealed that both R1 and R2 had lost their partners, who also resided at the facility, a few months prior. Due to R1’s diagnosis of MCI and R2’s diagnosis of dementia, staff interviews indicated that R2 may have confused R1 with their late spouse. Staff reported that at the beginning of R1 and R2’s relationship, R2 spoke to R1 in a stern manner, frequently questioned R1’s actions, and at times raised their voice when speaking to R1. These behaviors, along with other concerns, prompted facility staff to increase supervision of R1. Report Continued on LIC 9099C... Report Continued from LIC 9099C... Staff further stated that, regardless of R2’s manner of speaking, R1 would seek out R2 daily, and R2 would likewise seek out R1. Staff reported that although they cannot prohibit R1 and R2 from seeing one another, boundaries have been established to ensure that the residents are not alone together and are not permitted to be in either resident’s room without supervision. Staff further reported that following a change in R2’s condition and adjustments to their medications, R2 no longer confuses R1 with their late spouse and, as a result, has not spoken inappropriately to R1 for several months. Furthermore, although both R1 and R2 denied the allegation, staff interviews corroborated that, at times, R2 did speak inappropriately to R1 during the early stages of their relationship. Based on the information gathered during the course of the investigation, the Department has sufficient evidence to say a violation occurred. Therefore, allegation “Due to Staff Neglect / Lack of Supervision: Staff did not prevent resident in care from being verbally abused at the facility” is deemed Substantiated at this time. Exit interview conducted. Report and appeal rights discussed and copy was provided.