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32 | An interview with a staff member (S1) indicated that the licensee and administrator were informed of a residents (R1) history of sexually inappropriate behavior before R1's admission to the facility. An interview with R1's responsible party confirmed that this extensive history was disclosed to the administrator prior to placement. Despite awareness of R1’s behaviors, R1 was admitted to the facility without documentation of these behaviors in R1’s Admission Agreement or care plan. Department interviews with staff confirmed that, on November 12, 2022, R1 engaged in sexually inappropriate contact by touching two residents (R2 and R3), on their bare chests. Following this incident, facility staff and the licensee were notified of R1’s need for one-on-one supervision to ensure the safety of other residents. After R1 was taken to the hospital and returned to the facility, an increased level of supervision was added to R1’s care plan. However, R1 continued to move around the facility unsupervised, ultimately resulting in additional incidents where R1 inappropriately touched two more residents (R4 and R5), on December 12, 2022.
Today, December 4, 2024, the Department will be issuing a civil penalty per Health and Safety code § 1569.49 in the amount of $10,000 for a violation that the department determines was caused by the absence of one-on-one supervision as required by statute or regulation, resulting in multiple residents being sexually assaulted. However, since an immediate civil penalty of $500 was issued on May 4, 2023, the amount today will be $9,500.
A copy of the LIC 421D was given to Administrator and originals were signed.
Exit interview conducted. Appeal Rights provided. A copy of the report issued. Signature on this report acknowledges receipt of these rights, found on page 2 of the LIC 421D. |