Health inspection·March 20, 2025

F600 (Rev. 211; Issued: 02-03-23; Effective: 10-21-22; Implementation: 10-24-22) §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident’s medical symptoms. §483.12(a) The facility must— §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion.

F689 42 CFR §483.25(d) Accidents. The facility must ensure that – §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. On 2/4/2025, an unannounced visit was conducted by California Department of Public Health (CDPH) at the facility to investigate a facility reported incident regarding Certified Nursing Assistant 1 (CNA 1) who witnessed Resident 1 kissing Resident 2 on the lips. In addition, Resident 2 stated that Resident 1 touched her private area without consent. The facility failed to supervise Resident 1, who had history of sexually inappropriate behaviors toward others, by failing to protect Resident 2 when Resident 1 wandered inside Resident 2’s room on 1/31/2025, in accordance with Resident 1’s care plan for “Behavioral symptoms: Sexual inappropriate/disruptive behavior towards others”. This resulted in Resident 2 to experienced sexual abuse (non-consensual sexual contact of any type with a resident) that may impair the resident’s psychosocial well-being and not feel safe at the facility. A review of Resident 1’s Admission Record (AR), the AR indicated Resident 1, a 27-year-old-male, was admitted to the facility on 11/3/2021, with diagnoses that included schizoaffective disorder (mental illness can combines disorganized thinking and inappropriate behavior) and intermittent explosive disorder (a condition that involves impulsive and aggressive outburst). A review of Resident 1’s History and Physical Examination (HPE, a comprehensive physician’s note regarding the assessment of the Patient’s health status) signed by the attending physician on 11/29/2024, the HPE indicated Resident 1 had a mental illness. A review of Resident 1’s Minimum Data Set (MDS, a resident assessment and screening tool) dated 11/10/2024, the MDS indicated the Resident 1 had intact cognition (thought process). A review of Resident 1’s care plans titled “Behavioral symptoms: Sexual inappropriate/disruptive behavior towards others”, the care plan indicated on 1/30/2022, Resident 1 touched a female resident’s breast. The care plan indicated another incident on 8/1/2022 where Resident 1 grabbed a female resident’s breast. The care plan indicated another incident on 8/21/2023 where Resident 1 kissed and touched a female resident and told her not to say anything. The care plan indicated another incident on 9/15/2023 where Resident 1 touched a female resident’s buttock during group activity. The care plan indicated another incident on 1/31/2025 where Resident 1 had a sexually inappropriate behavior towards a female resident. A review of Resident 1’s Change in Condition (COC) dated 1/31/2025 timed at 11:17 PM, the COC indicated that Resident 1 had a sexually inappropriate behavior. A review of Resident 1’s “Post Event Review (PER)” notes dated 2/3/2025 timed at 1:38 PM, the PER indicated that an Interdisciplinary Team met to discuss Resident 1 sexually inappropriate behavior towards Resident 2. The PER indicated that Resident 1 entered Resident 2’s room and kissed her. A review of Resident 1’s Handwritten Sexual Consent note undated, given to Resident 2 indicated that Resident 1 made love with Resident 2 consensually both were okay with the following terms and or activities: kissing, oral or anal sex (Oral sex -mouth-to-genital contact, Anal sex -penis-in-butt intercourse) and love making. A review of Resident 2’s AR indicated Resident 2, a 28-year-old-female, was admitted to the facility on 1/29/2025, with diagnoses that included mild intellectual disabilities (condition that affects a person ' s ability to learn and think) and intermittent explosive disorder. A review of Resident 2’s HPE, signed by the attending physician on 1/31/2025, the HPE indicated Resident 1 had a mental illness. A review of Resident 2’s Change in Condition (COC) dated 1/31/2025 timed at 11:38 PM, the COC indicated that Resident 2 was the victim of a sexually inappropriate behavior. A review of Resident 2’s “Post Event Review (PER)” notes dated 2/2/2025 timed at 1:51 PM, the PER indicated that an Interdisciplinary Team met to discuss Resident 1 sexually inappropriate behavior towards Resident 2. The PER indicated that Resident 1 entered Resident 2’s room without permission and kissed Resident 2. A review of Resident 1’s Progress Notes dated 2/1/2025 timed at 12:14AM, indicated on 1/31/2025 at 8:40 PM Resident 1 was not in his room in the B building and CNA 1 had seen Resident 1 in building C near the Shower Room. The progress note indicated at 8:41 PM CNA 1 reported to Program Counselor (PC) 2 that Resident 1 was seen in building C. The progress note indicated PC 2 contacted PC 3 who was watching the nursing station/courtyard in building C. The progress note indicated at 8:43 PM PC 3 decided to do a safety room check starting with Resident 2 room. The progress note indicated that PC 3 found Resident 1 in bed with Resident 2 under the covers. The progress note indicated PC 3 asked Resident 1 what he was doing, but Resident 1 did not answer and got out of bed and walked out of Resident 2’s room. A review of CNA 1’s Handwritten Investigation Statement dated “1/31/2025,” indicated at 8:30 PM CNA 1 witnessed Resident 1 at the entrance of building C. CNA 1 further wrote she told Resident 1 to go back to his room and saw Resident 1 walk back to his room. A review of PC 1’s Handwritten Investigative Statement dated “1/31/2025,” indicated PC 1 stated at 8:40 PM he overheard CNA 1 report to PC 2 that CNA 1 saw Resident 1 at the entrance to building C. PC 1 further wrote he prompted PC 3 to check on the residents on his assigned area in building C. PC 1 further wrote that PC 3 approached Resident 2’s room and when he entered, Resident 1 was in bed with Resident 2 with their clothes on. A review of PC 2’s Handwritten Investigative Statement dated “1/31/2025,” indicated at 8:40 PM PC 2 was at the program manager’s office with PC 1. PC 2 further wrote that CNA 1 had reported that Resident 1 was in building C waiting to speak with someone. PC 2 further wrote PC 1 prompted PC 3 to check on the residents in building C to ensure the residents were safe. PC 2 further wrote that Resident 1 was found in Resident 2’s room in bed with her. A review of PC 3’s Handwritten Investigative Statement dated “1/31/2025,” indicated PC 3 was notified by PC 1 at 8:42 PM to keep an eye on Resident 1. PC 3 further wrote he then went to Resident 1 room in building B. Resident 1 was not in his room. PC 3 further wrote he went into building C to do a safety check on the female resident’s rooms. PC 3 further wrote he first checked Resident 2’s room and found Resident 1 in bed with Resident 2 covered with a blanket. PC 3 further wrote Resident 2 was lying flat in bed and Resident 1 was lying down on his left side facing Resident 2. PC 3 further wrote when he questioned Resident 1, Resident 1 did not respond then stood up and walked out and back to his room. A review of PC 4’s Handwritten Investigative Statement dated “1/31/2025,” indicated PC 4 was monitoring all the residents in building B and saw Resident 1 leave his room to go to the dining room and was talking with CNA 1. A review of the facility’s Unusual Occurrence Reporting Form dated 2/3/2025, indicated on 1/31/2025 at 8:40 AM, CNA 1 saw Resident 1 standing near Building C male shower room. The form indicated that CNA 1 told Resident 1 to return to his room and at approximately 8:41 PM, CNA 1 went to the program office to notify PC 2 and PC 1. The form indicated at 8:42 PM PC 1 notified PC 3 who was watching Building C and the courtyard that Resident 1 was seen in Building C. The form indicated at 8:43 PM PC 3 decided to do a resident safety check and went to Resident 2’s room. The form indicated when Resident 2 was questioned she stated that she signed a letter but did not know what she signed because was half asleep. The form indicated that Resident 2 stated Resident 1 kissed her on the mouth and touched her private area over her pants. The form indicated Resident 2 stated the sexual act was not consensual. The form indicated Resident 2 wanted to press charges against Resident 1. The form indicated on 2/2/2025 law enforcement came to the facility to investigate the sexual abuse complaint and when they interviewed Resident 1, he stated to the police “I plead the fifth.” The form indicated that the police stopped the interview and transferred the case to suspicious circumstance sexual battery and a detective would be coming to the facility to follow up the investigation. A review of the Report Information and Victims Bill of Rights dated 2/3/2025, indicated Police Officer (PO) 1 and labeled the incident as suspicious circumstances sexual battery. During an interview on 2/4/2025 at 9:45AM, the Administrator (ADM) stated that Resident 1 had entered Resident 2 room unwitnessed by staff. The ADM stated that Resident 1 kissed Resident 2 on the lips, and he was touching Resident 2’s private area and both residents were clothed. The ADM stated that Resident 1 had a history of sexual inappropriate behavior of touching female residents such as kissing and touching their breast and vagina while clothed. The ADM stated Resident 1 was not on any special monitoring such as 1:1 supervision (a staff member stays within arm's length of a patient to ensure their safety, especially for those at risk of harm or who may be cognitively impaired.) prior to the incident on 1/31/2025. The ADM stated that Resident 1 will be on 1:1 monitoring until they find placement for a higher level of care. The ADM stated that Resident 2 filed charges with the local law enforcement for sexual battery against Resident 1. The ADM stated the afternoon of the incident, the counselors and nursing staff should have been watching Resident 1 closely but did not, which led to Resident 1 entering Resident 2’s room undetected, and sexually abusing Resident 2 by kissing her lips and touching her private area without her consent. The ADM stated that Resident 1 wrote a handwritten consent and Resident 2 initialed it without knowing what the purpose of the consent was for. The ADM stated that Resident 1 consent was not a legal consent and stated that the social worker does the consent form with a witness if two residents want to consent to have sexual intercourse. During an interview on 2/4/2025 at 10:00 AM, Resident 2 stated Resident 1 had entered her room late at night on 1/31/2025. Resident 2 stated that Resident 1 made her sign a piece of paper that was for sex and she was half asleep. Resident 2 stated she did not want to be touched, kissed or have sex with Resident 1. Resident 2 signed the paper because she was in fear and in a state of shock. Resident 2 did not scream for help because she was in shock and did not want to wake the other residents. Resident 2 stated she was in the room alone prior to Resident 1 entering the room. Resident 2 stated after she initialed the paper that Resident 1 pulled the bed sheet over their heads and Resident 1 began kissing Resident 2 on the lips and with his right hand was touching her private area in an up and down motion. Resident 2 stated Resident 1 was in the room with her alone with Resident 1 for a few minutes before a staff member entered the room and asked Resident 1 what he was doing. Resident 2 stated Resident 1 just left the room after being questioned by the staff. Resident 2 stated she was pressing a sexual assault charge against Resident 1. During an interview on 2/4/2025 at 11:25 AM, the Program Director (PD) stated that on 1/31/2025 she spoke with the nursing staff and counselors for the 3PM -11PM shift prior to leaving the facility at around 4PM that the staff were supposed to monitor Resident 1 closely for inappropriate sexual behavior towards any of the female residents. PD stated that her staff failed to monitor Resident 1 because he was able to find a way into Resident 2 room and started kissing her lips and touching her private area without her consent. PD stated that Resident 1 had a handwritten consent was not a legitimate. PD stated that this occurrence could have been prevented had the facility staff listened to her specific instructions to monitor Resident 1 closely. PD stated that prior to this incident Resident1 was not on any 1:1 monitoring. During an interview on 2/4/2025 at 11:43 AM, the Program Manager (PM) stated that she worked on 1/31/2025 and left the facility at around 8:15 PM. PM stated that she did a walk thru the entire bungalow area prior to exiting the facility and Resident 1 was in his room at the time. PM stated at 8PM residents are in their rooms for room relaxation time. PM stated at 8:53 PM she received a text message from PC 1 regarding Resident 1 entering Resident 2’s room and Resident 1 had kissed Resident 2 on the lips, and he had touched Resident 2 in her private area. PM stated that PC 1 had sent her a picture of Resident 1 handwritten consent form to have sex with Resident 2. PM stated that the consent form was not a legitimate form. PM stated at 8:40PM CNA 1 had redirected Resident 1 to go back to his room turned her back and went to report Resident 1 to PC 1 and PC 2. PM stated PC 1 notified PC 3 who was supposed to be watching Building C and the courtyard. PM stated at 8:43PM PC 3 did a safety check in building C knocked on Resident 2 room and found Resident 1 and Resident 2 under the covers in bed together. During a phone interview on 2/4/2025 at 2:46PM, PC 3 stated that PC 4 was in charge of watching the residents in building B at 8 PM and that Resident 1’s room was in building B. PC 3 stated he was in charge of watching the female residents in Building C and the courtyard. PC 3 stated at around 8:46 PM or 8:47 PM he was