Complaint Investigation Report

157209257-7-1-2025-24-AS-SMOA-DJCMNB-20250707094517

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

This is an official report of an unannounced visit/investigation of a complaint received in our office on

06/06/2025 and conducted by Evaluator Mai Yang

COMPLAINT CONTROL NUMBER: 24-AS-20250606141950

Resident was sexually assaulted by another resident while in care.

Staff not able to assist residents in a timely manner due to short staff.

On 07/01/25, Licensing Program Analyst (LPA) M. Yang arrived unannounced to delivered complaint findings. LPA met with Administrator Pamela Bradley.

During the course of the investigation, the department conducted interviews, toured the facility, and reviewed records. The department observed all nonambulatory and bedridden female residents’ room in memory care were locked and inaccessible to other residents. Staff and residents were able to exit bedrooms. Staff were observed responded to call pendant timely pulled. Based on observation, the preponderance of evidence standard has not been met, therefore, the above allegations are found to be UNSUBSTANTIATED. An exit interview was conducted. A copy of this report was provided to the Administrator, whose signature on this form confirms receipt of this report.