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32 | During the assignment, S2 was initially identified as the alleged perpetrator, and R1 later identified S1; however, both staff denied the allegation. A full investigation was not opened at that time due to insufficient information and inconsistent statements from R1.
On 10/03/2025, LPA Huynh conducted an initial complaint visit. Between 3:23PM and 4:07PM, the LPA conducted a physical plant tour and reviewed and obtained pertinent documents. The ED was informed that the complaint allegation was referred to CCLD’s IB. Between 10/06/2025 and 12/29/2025, IB Investigator Rocio Flores conducted interviews with relevant parties including facility staff, residents, and family. Investigator Flores also obtained and reviewed additional documents including hospital records, law enforcement reports, and sexual assault medical examination records.
During today’s visit, the LPA and ED conducted a physical plant tour at 12:39PM, and no immediate concerns were observed. The following was then determined:
Allegation: “Staff sexually assaulted resident in care”
It was alleged that R1 was sexually assaulted by S1. Physician’s Report dated 08/07/2024 documented R1’s diagnoses, including bipolar disorder, schizophrenia, major depression, and mild cognitive impairment. An Individual Service Plan dated 03/17/2025 indicated R1 exhibited confusion, forgetfulness, a history of head trauma, and required staff redirection.
R1 reported to Investigator Flores that on 08/02/2025, S1 entered their room and inserted their fingers or genitals into R1’s anus. R1 recalled feeling “internal pain” due to the use of force and expressed uncertainty, stating they may have been “hallucinating.” R1 further stated they were taken to the hospital on 08/06/2025 after Staff #3 (S3) observed blood in their feces.
Report Continued on LIC 9099-C |