On the allegation Sexual Abuse, it is the concern of the reporting party (RP) that Staff #1 (S1) sexually assaulted Resident #1 (R1) and engaged in sexual relations with Resident #2 (R2). To investigate this complaint on 04/09/2025, Inv. Padilla conducted a visit to the facility and reviewed and requested copies of R1, R2, and S1 files, as well as S1’s work schedule from 03/01/2025 to 04/30/2025. On 03/20/2025 at approximately 2:50 p.m., a telephonic interview was conducted with Staff #2 (S2). On 03/28/2025 at approximately 11:40 a.m., an in-person interview was conducted with R1; at 1:00 p.m., an in-person interview was conducted with Staff #3 (S3). On 04/02/2025 at approximately 9:10 a.m. and 12:40 p.m., electronic correspondence via email was exchanged with an LAPD Detective. On 04/07/2025 at approximately 3:26 p.m., an additional interview was conducted with S2. On 04/08/2025 at approximately 8:20 a.m., a telephonic interview was conducted with R1. On 04/08/2025, Investigator Padilla conducted a visit to the facility; at approximately 10:40 a.m., an in-person interview was conducted with R2; at approximately 11:40 a.m., video footage was reviewed and obtained. On 04/09/2025 at approximately 8:45 a.m., electronic correspondence via email was exchanged with LAPD Detective. On 04/16/2025 at approximately 2:10 p.m., a telephonic interview was conducted with an Ombudsman from the Wise and Healthy Aging Ombudsman Office. On 04/23/2025 at approximately 3:55 p.m., electronic email correspondence was received from the facility containing S1’s timesheet from 03/26/2025 to 04/10/2025. On 04/25/2025 at approximately 2:50 p.m., a telephonic interview was conducted with LAPD Detective. On 04/28/2025 at approximately 1:50 p.m., a telephonic interview was conducted with the Ombudsman Supervisor from the Wise and Healthy Aging Ombudsman Office. On 05/16/2025 at approximately 9:30 a.m., Home Health records for R2 were subpoenaed; on 05/19/2025 at approximately 2:10 p.m., the records were received. On 06/02/2025 at approximately 11:15 a.m., a telephonic phone call was received from the facility’s Executive Director (ED) Angelito Vitug. On 06/12/2025 at approximately 1:41 p.m., a telephonic phone call was received from LAPD Detective. On 07/08/2025 at approximately 10:05 a.m., a telephonic interview was conducted with LAPD Detective. On 07/14/2025 at approximately 11:50 a.m., a telephonic interview was conducted with the Power of Attorney (POA) for R2. On 08/12/2025 at approximately 1:30 p.m., an in-person interview was conducted with R1. On 08/22/2025 at approximately 1:40 p.m., a telephonic call was received from the ED. On 08/26/2025 at approximately 1:30 p.m., a visit to the facility was conducted to review files and collect pertinent documents relevant to the investigation; at approximately 2:30 p.m., a telephonic interview was conducted with the facility Pharmacist/Supervisor. On 08/29/2025 at approximately 9:30 a.m., a telephonic interview was conducted with Staff #4 (S4). Report continued on LIC 9099-C PAGE 3...

On 09/03/2025 at approximately 12:30 p.m., a telephonic interview was conducted with the Primary Care Physician (PCP) for R2. On 09/04/2025 at approximately 11:20 a.m., a visit to the facility was conducted and an interview was held with the ED. On 09/04/2025, a subsequent interview was conducted with the ED and an interview was conducted with Facility Manager Joselito “Joey” Vitug. On 09/11/2025 at approximately 9:05 a.m., a phone call was received from LAPD Detective. Several attempts were made during the investigation to interview S1. Although S1 was unavailable to be reached for interview.

According to R1’s Physician Report, dated 02/16/2022 R1’s primary diagnosis is listed as Gait D/O, Neuropathy, and Hypokalemia, Requires medication management. R1 uses alcohol, motor impaired/paralyzed, and uses an electric wheelchair, and has a history of skin condition or breakdowns – skin tears. R1 can follow instructions, communicate needs, and leave the facility unassisted. R1 is unable to bathe, dress, groom, or manage toileting independently. R1 unable to independently transfer to and from bed.

According to R2’s Physician Report, dated 03/05/2021 R2’s primary diagnosis is listed as Paranoid Schizophrenia, COPD, and Mood Disorder. R2 unable to manage treatment/medication/equipment. R2’s Secondary Diagnosis is listed as Major Depression, Seizures, Insomnia, and encephalopathy, R2 unable to manage treatment, medication, and equipment. R2 is on a Special Diet. R2 presents episodes of confusion but remains capable of following instructions and effectively communicating personal needs. R2 is diagnosed with depression and requires support with Activities of Daily Living (ADLs). Additionally, R2 is unable to independently manage medications and relies on staff assistance for proper administration and oversight. According to R2’s Physician Report, dated 03/17/2023 R2’s primary diagnosis is listed as Bipolar, COPD, Mood Disorder, and Depression, R2 is unable to manage treatment, medication, and equipment. R2’s Secondary Diagnosis is listed as Seizures and Insomnia. R2 is on a Special Diet. R2 exhibits episodes of confusion but remains capable of following instructions and effectively communicating personal needs. R2 has been diagnosed with depression and requires support with Activities of Daily Living (ADLs). Additionally, R2 is unable to independently manage medications and relies on staff assistance for proper administration and oversight. According to R2’s Physician Report, dated 05/09/2025 R2’s primary diagnosis is listed as Bipolar, COPD, Mood Disorder, and Depression B and C. R1 needs assistance managing their treatment and medication.

Report continued on LIC 9099-C PAGE 4...

R2 experiences episodes of confusion but can follow instructions and communicate personal needs. R2 is diagnosed with depression and requires assistance with Activities of Daily Living (ADLs). R2 is unable to leave the facility without supervision. R2 is capable of administering injections independently. R2 requires assistance with medication administration, including PRN (as-needed) medications, and support with proper medication storage.

According to R2’s Department of Health Care Services (DHCS), Individual Service Plan (ISP) dated 04/21/2025 - 10/21/2025 is diagnosed with Paranoid schizophrenia, unspecified encephalopathy. COPD, seizures, extrapyramidal & movement disorder, mood affective disorder, anxiety disorder, major depressive disorder, insomnia, and generalized weakness. Due to R2’s diagnosis, R2 has difficulty understanding their own personal care needs. With the assistance of staff, they are able to manage many of these needs with little issues. It was noted that R2 is Alert and Oriented to Person and Place with periods of confusion and forgetfulness. R2 does not require assistance with making decisions and being aware of their needs. R2’s POA is the one who assists with making decisions.

Interview with R2’s PCP revealed that they are the PCP for several residents including R2, staff, and the owner of Residences at Royal Bellingham. They visit the facility once a month, or more frequently if necessary. PCP knows R2 very well because they live in the facility as they have significant psychiatric conditions and are currently prescribed psychotropic medications as part of their treatment plan, however they are currently managing well with it.

The review of facility records including but not limited to S1 work schedule from 03/01/2025 to 04/30/2025 indicated that S1 was scheduled off on 03/06/2025, 03/13/2025, 03/18/2025, 03/23/2025, 03/30/2025, 04/03/2025, 04/08/2025, 04/24/2025. S1 employee file and trainings including Relias, one (1) hour training on Abuse, Neglect, and Exploitation in the Elder Care Setting dated 12/29/2024, Relias, twenty-five-minute (.25) training on Care of Bedridden Residents dated 12/23/2024. It was noted that all documents that require an address are blank in the address section. However, S1’s CA ID lists the facility address.

Video footage obtained on 04/08/2025 at 11:40 a.m. revealed that on 03/30/2025, at 7:58 p.m. S1 was wearing a black t-shirt and shorts, walked towards R2’s room. S1 had the door keys in hand, opened the door, and entered the room. On 03/30/2025 at 8:18 p.m., the door of R2’s room opens, and S1 exits the room.

Report continued on LIC 9099-C PAGE 5...

Interviews with R1 revealed that they no longer reside at the facility, having moved out approximately two (2) years ago. R1 lived at the facility for about four (4) months. While R1 generally liked living at the facility, they expressed dissatisfaction with the caregivers’ response time. R1 stated that some male staff appeared to be inappropriate, describing instances where they made suggestive comments during diaper changes and were occasionally rough. R1 recalled experiencing inappropriate remarks from a male caregiver during one (1) or two (2) diaper changes but chose to "brush it off." R1 reported that during a diaper change, a male staff member, name unknown, inserted a finger into their vagina multiple times to remove feces, while making flirtatious remarks. Additionally, R1 stated that they did not witness any inappropriate physical contact by any caregivers. During an attempted second interview on 04/08/2025, R1 claimed to be unaware of any alleged incidents and did not wish to be interviewed.

Interviews with R2 revealed that they have lived at the facility for approximately three and a half (3.5) years and have had an overall positive experience. R2 requires assistance with medication management, transportation, and visits to their PCP, who is based at the facility. During the day, R2 is typically assisted by female caregivers, while male caregivers are assigned during the night. R2 stated that during room checks, caregivers knock and use a key to open the door, although R2 usually opens the door themselves. R2 reported that they have never been touched inappropriately, nor have they witnessed any other resident being touched inappropriately. R2 disclosed that they are secretly in a relationship with S1, though they do not publicly display affection. The relationship began as a friendship. R2 initially denied that S1 spent time in their room or that any sexual contact occurred. However, R2 later stated that they had been dating S1 for approximately two (2) years. S1 hugs, kisses, and checks in on R2 to ensure they are okay. R2 later acknowledged that they are intimate with S1, although it is infrequent and occurs approximately once every two (2) months. Intimacy typically begins with text messages of a romantic nature. Sexual activity takes place in R2’s room at the facility, usually during nighttime hours between 8:00 p.m. and 9:00 p.m. S1 would remain in the room for approximately 30 minutes to an hour before leaving. R2 stated that S1 was aware of the potential consequences if they were caught and expressed that they do not want S1 to get into trouble. S1 had informed R2 that they were aware of the camera placement, including one positioned at R2’s door. The last reported instance of sexual activity between S1 and R2 occurred on 03/30/2025 at approximately 8:00 p.m. and lasted about 15–20 minutes. S1 did not stay long due to concerns about the cameras.

Report continued on LIC 9099-C PAGE 6...

Interviews with POA of R2 revealed that they were aware of the relationship between R2 and S1. The POA stated they learned of the relationship approximately two (2) years ago but were unaware that it was ongoing. Upon being informed of the relationship, the POA contacted the facility’s Executive Director (ED) to verify its validity. The POA reported that the ED denied the allegation. The POA noted that both they and the ED work at licensed facilities and are required to comply with Title 22 regulations, or risk facing consequences. The ED stated that they were “just friends.” The POA acknowledged that R2 can sometimes fabricate stories, and since the ED denied the claims, they chose not to pursue the matter further. The POA emphasized that based on R2’s diagnosis of Schizophrenia and their most recent evaluation, R2 lacks the capacity to consent to a relationship or engage in sexual activity; hence, the POA was established. The POA believes R2 does not possess the ability to understand or make informed decisions, making it difficult to be in a relationship or consent to sexual activity. Although R2 occasionally presents well and appears alert when making decisions about daily activities, such as choosing clothing or deciding where to go, they continue to experience delusions. The POA expressed disbelief that the facility would permit such a relationship to occur. They added that R2 is a patient and S1 is a caregiver. Additionally, the POA stated that both the facility’s ED and Manager were aware of the relationship, as they had inquired about it. Furthermore, the POA asserted that regardless of S1’s intentions, the situation constitutes abuse. R2 is a patient at the facility, and regardless of how the situation is framed, the relationship should not have occurred. The POA concluded that management staff should never have allowed the situation to happen.

Interviews with former staff revealed that multiple serious concerns had been reported at the facility, including harassment, inappropriate conduct, and sexual behavior by S1. Allegations of both past and ongoing sexual abuse were also raised. Staff described S1’s behavior as involving romantic entanglements, verbal abuse, and suspected manipulation of vulnerable residents. S2 reported that S1 disclosed to them on two (2) separate occasions that they had inserted their finger into R1’s vagina during a diaper change, stating it was due to the presence of feces. S2 expressed uncertainty about S1’s comment and did not understand why S1 told S2 this on two different occasions and suggested it might be an attempt to appear “macho” or impress S2. Additional concerns included claims that management either ignored or protected problematic behavior.

Report continued on LIC 9099-C PAGE 7...

Interviews with the Facility Manager (FM) Joselito “Joey” Vitig revealed that they were aware of rumors regarding S1 and R2 but had no direct knowledge or formal reports confirming a relationship. The FM considered their friendship acceptable but acknowledged that a sexual relationship would be inappropriate. The FM confirmed viewing video footage of S1 entering R2’s room and noted that the interaction appeared to be expected by both parties. The FM denied receiving any reports of inappropriate touching by male staff and emphasized that staff-resident relationships are strictly prohibited. Additionally, the FM stated that the facility has since implemented improvements, including enhanced staff training and the hiring of additional female employees.

Interviews with the ED revealed that the facility did not have a formal policy regarding staff-resident relationships or off-duty visits, although such relationships are prohibited under Title 22. R2’s POA had spoken with the ED about a possible romantic relationship between R2 and S1; however, a romantic relationship was never confirmed. The ED stated that if such a relationship had been verified, S1 would have been terminated. The ED denied receiving any reports of inappropriate touching or misconduct involving S1 and asserted that any such behavior would have resulted in immediate termination. Furthermore, the ED confirmed that S1 served as the lead caregiver responsible for managing staff schedules and duties. The ED was unaware that S1 had listed the facility’s address on their identification card. The ED stated that S1 is no longer employed or associated with the facility, citing complaints regarding S1’s demeanor. Additionally, the ED noted that improvements are being implemented, including the hiring of more female staff, and reaffirmed their commitment to protecting both residents and staff from misconduct and false accusations. Based on the Department’s investigation, there is sufficient evidence to support the allegation of Sexual abuse. Therefore, the allegation is deemed Substantiated at this time.

The following deficiency was observed (See LIC 9099-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. A $250 civil penalty is assessed for the citation related to CCR 87468.2(a)(8) for a repeat violation. Assistant Administrator and Executive Director were made aware that failure to correct the deficiencies may result in civil penalties. Assistant Administrator and Executive Director were also informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f). Exit interview conducted. A copy of the report and appeal rights were provided.