Investigation Revealed the Following:

Allegation: Staff did not prevent a resident from sexually abusing another resident

The details of the complaint alleged that (R#1) was sexually assaulted by (R#2).

On December 11, 2025, at approximately 12:00 p.m., during a review of records, Licensing Program Analyst (LPA) Iniguez observed Resident #1’s (R#1) Physician’s Report for Residential Care Facilities for the Elderly (LIC 602A), dated June 25, 2025. The report indicates that (R#1) has been diagnosed with a mental health condition that may influence their thought processes and belief system. Additionally, the LIC 602A form notes that (R#1) is confused and disoriented. LPA Iniguez also reviewed (R#1)’s current medication list, which includes a prescription for Haloperidol 50 mg to be administered every morning. This medication is associated with the management of (R#1)’s diagnosed mental health condition. Furthermore, LPA Iniguez reviewed (R#1)’s Appraisal/Needs and Services Plan (LIC 625), dated September 24, 2025, which states that the facility is responsible for monitoring R#1 throughout the day for any physical or mental changes.

On December 11, 2025, during an interview, the facility administrator (A#1) she stated that upon being notified of (R#1)’s allegation of sexual abuse by their mental health case manager, the facility took immediate action by assessing (R#1) and offering to relocate them to a different room once one becomes available. (A#1) also indicated that the Long-Term Care Ombudsman would be informed of the incident. To ensure (R#1)’s safety, the facility implemented a two-hour wellness check protocol, with staff monitoring (R#1) throughout the day and night for any physical or mental changes. In addition, (A#1) stated that in response to the allegation, the facility followed its internal abuse protocols by interviewing relevant parties, documenting the incident, and notifying Licensing, the Ombudsman, the mental health case manager, and (R#1)’s psychiatrist. The facility does not utilize in-room surveillance cameras due to resident privacy rights, which align with regulatory standards.

Evaluation Report continues LIC 9099-C

On December 11, 2025, at approximately 1:00 p.m., (W#1) stated that when a program client reports abuse, the department follows a protocol to ensure the client’s safety. This includes providing immediate access to medical and mental health support, formally reporting the incident to authorities. On January 20, 2026, (W#1) reported via email that after receiving the client’s report, they consulted their supervisor and the on-site clinician to confirm the facility was aware of the incident. That afternoon, (W#1) reported the incident to Adult Protective Services (APS) and was instructed to contact the Long-Term Care Ombudsman hotline. (W#1) then completed a SOC 431 form and emailed it to the Long-Term Care Ombudsman and Community Care Licensing. (W#1) also indicated that, to their knowledge, no investigation was initiated by them.

On December 11, 2025, at approximately 11:00 am, during an interview with (R#1), they stated that the alleged incidents occurred approximately 15 times over a period of three months. When asked whether the incidents were reported to facility staff immediately after they occurred, (R#1) stated that they did not report them at the time because they believed the behavior would stop on its own. In addition, (R#1) stated that since the report was made, (R#1) indicated that the facility has “placed a camera in their room” to monitor their safety. When asked if they currently feel safe living at the facility, (R#1) responded affirmatively, stating that they do feel safe now.

On December 11, 2025, at approximately 11:20 am, during an interview with (R#2), they stated that they do not engage in conversation with (R#1) and simply share the room for sleeping purposes. Also, (R#2) reported no knowledge of any concerns or complaints made against them by either their roommate (R#1) or facility staff. In addition, in response to the allegation of inappropriate physical contact involving (R#1), (R#2) firmly stated that they have never touched (R#1) in a sexual or harmful way and that they always maintain respectful and appropriate behavior toward them. When asked whether they feel safe living at the facility, the individual responded affirmatively.

Evaluation Report continues LIC 9099-C

On December 11, 2025, at approximately 11:30 am, during interviews with residents (R#3-R#10), (8) out of (8) stated that the facility consistently responds in a positive manner when asked about the facility’s response to resident concerns regarding safety, privacy, or personal well-being and, they affirmed that staff respond appropriately to both serious concerns and minor requests for assistance, based on their personal observations. In addition, (8) out of (8) residents stated that they have not observed or heard of any concerning incidents involving (R#1) and their roommate (R#2), and they feel safe living here.

During this investigation, LPA did not find sufficient evidence to support the above-mentioned allegation(s).

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

An exit interview was conducted, and a copy of the Complaint Report was given to Julian Villanueva/Resident Coordinator.