Facility Evaluation Report

Licensing Program Analyst (LPA) Kelly Dulek conducted a Case Management - Incident visit regarding a self-reported incident. LPA met with Administrator Ashiman (Ashi) Gill and Director of Health Services Heather Hampel and explained the reason for the visit.

On 05/04/2026, LPA Dulek received a telephone call from the management team indicating that during a care conference that day, a family member reported an alleged incident involving Resident #1 (R1) and Staff #1 (S1). An incident report and suspected abuse report was submitted to the Woodland Hills Regional Office (RO) on 05/05/2026. Incident Report indicated R1 reported to their family member that on 04/29/2026, S1 had put their finger inside R1 while S1 was assisting R1 with their shower. While R1 reported to their family member timely, R1's family member did not inform the facility until 05/04/2026. Immediately following knowledge of the alleged incident, facility management informed all relevant parties of the alleged incident and adjusted R1's care to include two (2) female staff during all personal care provided. Police responded to the facility, indicated there was no crime committed, and a written report was filed. The facility then conducted an internal investigation into the alleged incident.

During LPA's visit today, LPA discussed the incident report with Administrator and Director of Health Services at 10:32AM, toured the facility with Administrator at 10:40AM, LPA observed and talked with R1, and LPA obtained copies of pertinent documents. No immediate health and safety hazards were identified during facility tour.

Review of documents obtained and interview revealed at the time of the allegation, another staff, not S1 had been assisting R1 with their showers at that time and for approximately four (4) weeks prior to the alleged