Complaint·April 29, 2026

also reviewed documents, including but not limited to resident file information, shift notes, incident report, staff documents, and police report. Throughout the course of the investigation, LPA Dulek reviewed all relevant information obtained. The following was then determined: The complaint alleges that Staff #1 (S1) touched Resident #1 (R1)’s breast and pinched R1’s nipples during a haircut. Interview with R1’s mental health provider revealed that R1 had a noticeable change in behavior in November 2025. When asked, R1 did not wish to disclose what had upset them and R1 said they would deal with it. Later, R1 reported that while S1 was cutting R1’s hair, S1 pinched both of R1’s nipples and R1 slapped S1’s hand away. Interviews revealed that on or around 11/12/2025, R1 requested S1 cut their hair. S1 does cut various residents’ hair when requested, but typically the haircuts take place in a facility common area, such as the dining room. However, R1’s haircut took place in their room, where there are no cameras present. Interviews with staff and other credible persons revealed that R1 is honest and does not have any history of fabrication. Although S1 denied they inappropriately touched R1, S1 did acknowledge they may have “accidentally” touched R1’s breast during the haircut. During the investigation, Resident #2 (R2) reported they had sexual intercourse with S1 on two (2) occasions when S1 took R2 out of the facility for a drive. Interview with residents revealed that S1 is “really chummy with the females” and has been observed to pay special attention to R2 while at the facility. Staff interviewed also reported that S1 and R2 often sit together at the facility and leave together regularly, not only for scheduled medical appointments. According to R2, “everything [with S1] was consensual.” R2 indicated that approximately six (6) months ago during the summer, there were two (2) times R2 and S1 had sexual relations inside S1’s personal vehicle. The first incident involved physical contact, including touching and kissing, and S1 touched R2’s intimate areas. In the second incident, R2 reported having sexual intercourse with S1. S1 denied having any sexual relationship with R2. S1 smiled and laughed as S1 explained that it was R2 who made sexual advances toward S1, including R2 exposing themselves to S1. S1 did recount that on one occasion after their work hours, S1 observed R2 on the street and S1 offered R2 a ride in their personal vehicle. S1 acknowledged that it was inappropriate to drive a resident in a personal vehicle. This behavior violates the facility’s staff code of ethics, which S1 had signed on 09/12/2024. Documents reviewed and interviews with their respective mental health professionals confirmed that both R1 and R2 are conserved and unable to make their own medical or psychiatric decisions, including consenting to any type of sexual encounter. Therefore, although R2 indicated their interactions with S1 were Report Continued on LIC 9099-C “consensual,” R2 acknowledged it was inappropriate for any resident to have this type of relationship with a staff member due to the various mental health issues the residents in the facility have been diagnosed with. Many residents in the facility were aware of the allegations and reported concern for both R1 and R2 in their interactions with S1. Additional mental health professionals working with various residents in the facility expressed concern for not just R1 and R2, but the psychological impact this inappropriate behavior has had on many residents at the facility. Based on information gathered during the course of the investigation, there is sufficient evidence to support the allegation; therefore, the allegation “staff engaged in inappropriate sexual behavior with resident(s)” is deemed SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiency was cited (refer to LIC 9099-D.) Facility Designee was informed that failure to correct the deficiency may result in civil penalties. Exit interview conducted, appeal rights discussed and a copy of today's report and appeal rights were provided via email.