Complaint Investigation Report

The RP alleged the facility failed to report an incident to law enforcement when staff found the resident naked showering and with the SA. Facility staff allowed SA to visit R1 for over a year unsupervised until SA was finally caught outside with their penis in R1’s mouth. SA was arrested and is currently being tried in criminal court. Lastly, RP alleges that R1 had been drugged.

After receiving a formal complaint, the LPA reviewed the facility’s history and determined that on 11/20/2023, 03/08/2024, 02/28/2025 Case Management (CM) visits had been conducted by either LPAs Campos and Peraldi or LPA Cortez regarding the incidents involving R1. Additionally, on 11/20/2023 these incidents were referred to and investigated by the Community Care Licensing (CCL) Investigations Branch (IB).

On 11/18/2023, the Department received a Report of Suspected Dependent Adult/Elder Abuse Report from the facility. The report advised on 11/18/2023, Resident #1’s (R1) family member/Suspected Abuser (SA) was observed with their penis in R1’s mouth. On 11/20/2023, the Department referred the case to the Community Care Licensing (CCL) Investigations Branch (IB). The case was assigned to Investigator Christine Ferris to conduct the investigation in reference to the allegation.

On 11/20/2023, from 1:50pm to 3:30pm, Licensing Program Analysts (LPAs) Elsie Campos and Emily Peraldi conducted an unannounced Case Management - Incident visit. At 1:55pm, LPAs Campos and Peraldi met with Administrator, Amber Winterstein and explained the reason for the visit. The reason for the visit was to follow up on a self-reported incident report received on 11/20/2023. The report pertained to a personal rights violation of Resident #1 (R1). At 1:58pm, the LPAs conducted an interview with the Administrator. At 2:06pm, the LPAs obtained copies of pertinent documents. At 2:55pm, the LPAs along with the Administrator conducted a physical plant tour. No immediate health and safety concerns were observed during the inspection. The LPAs determined further investigation was needed and informed the Administrator that the investigation was assigned to the Community Care Licensing (CCL) Investigations Branch (IB).

On 12/04/2023, from approximately 11:00am to 1:30pm, CCL IB Investigator Ferris conducted interviews with R1, Administrator, staff, and residents; on 12/19/2023, from approximately 11:30am to 1:00pm, with staff; on 01/19/2024 and 01/22/2024, attempted to contact the SA and left voice mails; and on 01/22/2024, at approximately 10:00am, with Detective Torres of the Ventura County Sheriff’s Department. In addition, Investigator Ferris requested Ventura County Sheriff’s Department Report #2023-147699 and facility file documents related to R1. Report will continue on LIC9099-C, 3rd page.