Complaint Investigation Report

Allegation: Staff did not provide adequate supervision resulting in resident sexually touching another resident.

As part of the investigation, the Department requested and reviewed a police report from the Glendale Police Department on 10/06/2025, conducted interviews with the Administrator and Resident #1 (R1) on 10/10/2025. The department reviewed surveillance footage on 10/10/2025, and interviewed a caregiver on 10/15/2025.

The investigation revealed that R1 has resided at the facility since March 2004 and Resident #2 (R2) has resided at the facility since October 2024. On 09/24/2025, law enforcement responded to the facility following a report that R2 engaged in inappropriate physical contact with R1 in the dining room.

On 10/10/2025, the Department interviewed R1. Due to diminished cognitive capacity associated with dementia, R1 was unable to provide a reliable statement regarding the incident.

The Department reviewed surveillance footage, which showed R1 seated in the dining room when R2 approached and made physical contact with R1's chest area over clothing. The footage showed R2 leaving the area immediately after the contact. Staff intervention occurred only after the contact had already taken place, at which time a staff member approached R1, adjusted R1's clothing, and checked on R1's well-being.

On 10/15/2025, the Department interviewed a caregiver who witnessed the incident. The caregiver reported observing R2 approach R1 and engage in inappropriate physical contact before leaving the dining room. The caregiver stated that they immediately checked on R1 and reported the incident to the Administrator.

During the investigation, the Administrator reported that R2 had a history of inappropriate behaviors and boundary violations involving other residents. The Administrator further reported that approximately one month prior to the incident, R2 was observed entering R1's room without authorization. Although that incident could not be conclusively substantiated due to insufficient evidence, it raised concerns regarding R2's interactions with other residents. The Department's review also identified repeated incidents and concerns involving inappropriate behavior by R2 toward both residents and staff prior to the 09/24/2025 incident.