425801723-10-23-2025-29-AS-KBUY-DMYN56-20251031100901

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425801723
Report Date: 10/23/2025
Date Signed: 10/23/2025 01:07:15 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/16/2025 and conducted by Evaluator Mark Jeffries

COMPLAINT CONTROL NUMBER: 29-AS-20250916155953

FACILITY NAME:	PRIMROSE		FACILITY NUMBER:	425801723
ADMINISTRATOR:	DOROTHY BERGER		FACILITY TYPE:	740
ADDRESS:	4630 SONG LANE		TELEPHONE:	(805) 310-6996
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93455
CAPACITY:	14	CENSUS: 10	DATE:	10/23/2025
		UNANNOUNCED	TIME BEGAN:	08:33 AM
MET WITH:	Administrator, Dorthy Berger		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Resident was sexually abused in facility.

INVESTIGATION FINDINGS:

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At 9:00am on 10/23/2025, Licensing Program Analyst (LPA) Jeffries arrived to the facility unannounced to issue final findings to the allegations to this complaint. LPA met with facility Administrator, Dorthey Berger, announced who he is and the reason for the visit was to issue final finding to the allegation to this complaint. LPA also conductd additioanl interviews.

On 09/16/2024, the Department received a complaint regarding an allegation of Sexual Abuse. The complaint alleged Resident 1 (R1) while in care suffered, multiple dark-purple bruises to the perineal area, suggesting sexual abuse while in care. The complaint was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Jorge Rojas.
On 09/17/2025, from 7:25am to 9:56am, LPA Jeffries arrived to the facility unannounced to conduct a health and welfare visit based on a personal rights allegation to this complaint. LPA met with Administrator, Dorthy Berger, announced who he is and the reason for the visit. LPA requested documentation. Administrator and LPA conducted a facility physical tour. CONTINUED on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20250916155953

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PRIMROSE	FACILITY NUMBER: 425801723
	VISIT DATE: 10/23/2025

NARRATIVE

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LPA observed residents in care, 6 of 11 residents in the common room, 3 of 11 residents were in their bedrooms and two residents not currently in the facility. At time of visit Resident 1 (R1) was in the hospital. LPA needed more time to conduct investigation, conduct interviews, review and request documentation, and will return at a later time to issue final findings.

On 09/18/2025, Investigator Rojas requested medical records for R1 from Marian Regional Medical Center. A review of medical records on 09/22/2025 shows that on 09/09/2025, R1 was hospitalized due to a fall and a nurse noted bruising over the upper bony area of the vagina, and a laceration with oozing was also noted. However, 50 minutes later, another nurse corrected the statement and removed “bruising to top of boney area of vagina.” On 09/14/2025, notes state a nurse observed dark purple bruising on the clitoral hood, vaginal canal, and bilaterial labia majora. On 09/14/2025, R1 tested negative to any blood borne diseases. On 09/15/2025 R1 was seen by a physician, who noted no signs of excoriation or bruising on the exam around the genitalia area. On 09/15/2025, another physician noted that R1 reported generalized aches but could not specify the pain’s location or nature. Medical records indicate R1’s family member (F1) observed increased confusion and attributed the vaginal bruising to a fall three of four weeks ago, expressing doubt of elder abuse. Another family member (F2) agreed, stating they would be surprised if abuse occurred at the facility, believed the bruising resulted from the fall on 09/09/2025, denied any concerns about abuse or neglect, and believes R1 would have spoken up if mistreated.

On 10/09/2025, Investigator Rojas contacted facility Administrator, Dorthy Burger who stated R1 was no longer residing at the facility. The facility had experienced a COVID-19 outbreak when R1 was ready to be discharged from the hospital, so R1’s family chose to relocate them to a different facility. On 10/09/2025, Investigator Rojas contacted F2 by phone, but F2 declined to provide requested information to the investigator. The investigator determined what facility R1 was at and contact the administrator at the new facility on 10/10/2025. The administrator stated R1 arrived at the facility on hospice due to deteriorating health, was no longer able to communicate, and was showing signs of being near end of life per hospice staff; therefore R1 was not interviewed.

CONTINUED on LIC9099-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20250916155953

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PRIMROSE	FACILITY NUMBER: 425801723
	VISIT DATE: 10/23/2025

NARRATIVE

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On 10/23/2025, LPA Jeffries conducted staff interviews of 3 staff (S1, S2, and S3) who all stated that, they feel they feel confident in the facility direct care training and confident to meet the needs of the residents, all stated they have confidence in all the staff, and have no issues or concerns with staff care giving. On 10/23/2025, LPA Jeffries conducted interviews of 4 of 10 residents (R2, R3, R4, and R5) all Residents stated they feel staff is well trained, feel safe at facility and have no issues with staff. LPA not able to interview remaining 5 residents due to cognitive ability levels.

As a result of R1 having conflicting medical records that initially discussed bruising, then were deleted, and the physician’s exam concluded “no excoriations or genital bruising” were found. Based on medical records and interviews conducted, there is insufficient evidence to support that allegation of “Resident was sexually abused in facility.” Therefore the allegation is unsubstantiated at this time.

Exit interview, report read, and report provided.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025

LIC9099 (FAS) - (06/04)

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