Complaint Investigation Report

No updated resident appraisal observed. LPAs conducted interviews with the Administrator and nine (9) out of fourteen (14) residents, who were able to communicate. On 03/21/24, LPAs Panushkina and Ngo-Castanega along with the Investigator, Jose Santana, from the Investigation Branch conducted a subsequent visit to interview R1.

Investigator Santana, conducted interviews with, Resident #1/R1 (on 03/21/24, 3/29/24, 4/3/24 and 5/1/24), R2 (on 05/01/24), R3 (on 03/27/24), R1's Social Worker and Case Manager (on 03/19/24), Primary Care Physician (on 03/28/24). On 3/22/2024 IB subpoenaed R2 records from LASD Records and Identification Bureau. On 3/27/2024, IB also subpoenaed R1's medical records from 2/20/2024 – 3/27/2024.

Allegation: Resident was sexually abused by another resident in care.

The investigation findings revealed that in the morning of 02/20/24 R2 entered the room of R3 and asked to inappropriately touch R3. The facility became aware of the incident but failed to address the matter of R2 at that time. As a result, R2 then entered R1’s apartment on the afternoon of 02/21/24 and sexually assaulted R1. Although, during the interview with the Investigator, conducted on 03/29/2024, the Administrator denied knowing that R1’s allegation included actual touching, it was reported by a facility’s MedTech on 2/22/2024 and was documented on the SOC341 on 2/21/2024. The facility again failed to follow Brookdale’s Abuse Policy where it indicated the following: “Brookdale is committed to maintaining a safe environment for clients, visitors and associates. Allegations of abuse, neglect or exploitation should be treated seriously and be reported to the Administrator or the supervisor on duty for investigation and follow-up. Upon receipt of an allegation of abuse, neglect or exploitation, the Administrator or designee should conduct a confidential internal investigation of the incident within 24 hours. In the event of suspected rape or sexual abuse, the facility is to develop a plan as soon as possible to protect the suspected victim. The suspected victim should have a medical examination. Evidence or potential evidence should be preserved… The agency should contact an agency or individual trained in sexual abuse to interview the client and provide counseling…” Had the facility investigated the 2/20/2024 incident, there is a possibility that the 2/21/2024 incident could have been prevented. Furthermore, the facility did not notify R1 who his/her perpetrator was, although, R2 has since departed the facility. Instead, the facility did ask R1 to not discuss the incident with other residents. Therefore, based on interviews and information gathered during this investigation, this allegation is Substantiated. Continue on LIC9099-C