Wednesday, January 7, 2015

Linda Kincaid Reports: Community Care Licensing botched elder abuse, sexual assault investigation

On March 11, 2013, the family of Jean Swope reported that Jean may have been repeatedly sexually assaulted by a male caregiver at Wildwood Canyon Villa, a San Bernardino County, CA assisted living facility. Regulations require that Community Care Licensing (CCL) respond to a complaint within ten days.

Records from CCL show that Licensing Program Analyst (LPA) Susan Parker conducted the required “10-day” visit on August 1, 2013, nearly five months after the complaint. Parker determined the complaint “Needs Further Investigation.” CCL files show the next activity on the case was January 21, 2014, more than ten months after the complaint. 

LPA Parker neglected to inform Jean’s family of her findings. In order to review the investigation report, family had to drive over 400 miles from northern California to Riverside, where the physical file is located. Family informed CCL supervisor Sylvia Lucero nearly a week ahead of their visit to review the file. On the day family visited the CCL office, Wildwood’s file was not available. Family had to make a second trip to the CCL office to obtain a copy of the investigation.

LPA Parker wrote in her Complaint Investigation Report:
Allegation regarding resident # 1 may have been sexually abused: In late July, early August 2012 resident #1 had some bleeding issues. The allegation is that resident #1 may have been sexually abused by a male caregiver who worked the night shift.
LPA Parker neglected to mention that vaginal bleeding in an elderly woman is an indicator of sexual assault. Parker neglected to mention that Jean had a hysterectomy at age forty. Parker neglected to mention that Jean said of the male caregiver, “They say we have to get married. I will not marry that man.”
This male staff person no longer works for Wildwood.
LPA Parker neglected to mention that Wildwood terminated the male staff person shortly after Jean’s vaginal bleeding.
LPA Parker reviewed resident #1’s file.
LPA Parker neglected to mention that Jean’s file showed she was terrified of the male caregiver. Jean had increased agitation on nights when the male caregiver was on duty. Jean fought, screamed, and begged for help. Wildwood responded by administering Ativan, Seroquel, and Haldol to “control agitation.”
LPA Parker neglected to mention that Wildwood “lost” records that would establish which caregivers were on duty in the six weeks prior to Jean’s vaginal bleeding and genital trauma.
In August 2012 resident #1 was taken to Kaiser Emergency due to increased bleeding. LPA reviewed the results of the ER visit from Kaiser and it did not indicate that the bleeding was due to possible sexual abuse.
LPA Parker neglected to mention that Wildwood’s records show Jean had blood clots and necrotic tissue in her vagina. Parker neglected to mention that Kaiser records show Jean had trauma to the tissues surrounding her vagina. Parker neglected to mention the Kaiser records show Jean was so terrified at the emergency room that she screamed and fought when the doctor attempted to perform an exam. Jean was sedated for an exam.

LPA Parker neglected to mention that Kaiser physicians stated they did not immediately suspect sexual abuse because Wildwood Canyon Villa did not report possible sexual abuse. Kaiser physicians expected Wildwood staff, as mandatory reporters, to fulfill their duty under California law.
LPA spoke with Memory Care Nurse Candi Hull. She stated that hospice was notified when the bleeding first occurred.
LPA Parker neglected to mention that under federal law, hospice only provides care for a terminal illness. Hospice does not provide care for injuries related to sexual assault. Wildwood did not report vaginal bleeding to Jean’s primary care physician at Kaiser. Wildwood did not report possible sexual assault to law enforcement, Adult Protective Services, or to CCL.
Hull also states that an outside company, Parent Care Management, contracted with Senior Home Caregivers to provide round the clock care to resident #1, so someone was always with resident #1.
LPA Parker neglected to mention that Candi Hull of Wildwood and Brian Davis of Senior Home Caregivers placed written instructions into Jean’s file. Private caregivers were instructed not to leave Jean alone unless a Wildwood staff person was with her. The private caregivers had permission to leave Jean alone with Wildwood’s male caregiver.
This was in addition to the care and supervision resident #1 received from Wildwood Canyon staff who provided care to resident #1.
LPA Parker neglected to mention that a 2012 investigation, during the time the repeated sexual assaults may have occurred, established that Wildwood caregivers had less than 45 minutes per day to provide the care needed by each resident. Another Wildwood resident who was just eight rooms away from Jean died in late 2011 due to neglect by Wildwood staff. Wildwood was cited for those deficiencies in providing care. The resident’s family sued Wildwood for wrongful death. To our knowledge, law enforcement did not investigate.
Hull was not aware of any concerns or problems with the male Wildwood Caregiver who provided care to resident #1. Therefore, the allegation is Inconclusive.
LPA Parker neglected to consider that Jean was terrified of the male caregiver, After Jean suffered vaginal bleeding and genital trauma, Wildwood quickly transferred Jean and terminated the male caregiver.

Legal counsel for Jean’s family took the deposition of the male caregiver. When asked under oath if he sexually assaulted Jean, the male caregiver exercised his Fifth Amendment right to avoid self-incrimination. He refused to answer any questions concerning employment from 2007 forward.

After Wildwood terminated the male caregiver, he worked for a number of other assisted living facilities and in-home care services in San Bernardino County. To our knowledge, CCL and the San Bernardino County Sheriff has done nothing to protect other vulnerable elders from sexual assault.

Readers who suspect a loved one may have been sexually assaulted by a male caregiver can contact this Examiner at

Full Article & Source:
Community Care Licensing botched elder abuse, sexual assault investigation


Betty said...

Thank heavens you're setting this record, Linda. How many cases just slip through and are never discovered?

Steve said...

It makes me wonder how many cases are just never even reported, let alone those that are botched.