Certified nursing assistant Matthew Fluckiger left Gayle a warning — right after she says he raped her twice in one hour at a La Mesa nursing home in January 2020 — that terrified the 62-year-old almost as much as the alleged attacks.
“He said, 'I know where you and your family live, so trust me, I know you're not going to say anything,'” said Gayle, who did not want her full name used. “'Even if you do, no one will believe you, they love me here.’”
Fluckiger, a tall, heavyset, bespectacled 36-year-old with missing teeth, had reason to believe he could victimize with impunity.
His alleged attack on Gayle was the fourth time between March 2017 and January 2020 that a woman living in an East San Diego County nursing home had accused him of a sex crime or misconduct.
Yet, records obtained by KPBS show that even though state investigators learned of the first allegation against Fluckiger in 2017, they allowed him to continue to work in nursing homes around scores of physically and mentally frail women.
In fact, documents reveal that the California Department of Public Health (CDPH), the agency responsible for protecting residents from abuse in nursing homes, didn't even take the step of suspending Fluckiger's certified nursing assistant (CNA) license as it investigated subsequent sexual assault allegations against him.
“This is perhaps the worst and most horrifying story of serial sexual assault that I have ever heard in the long-term care setting,” said Mike Dark, a lawyer for California Advocates for Nursing Home Reform (CANHR).
Dark argued that Fluckiger’s alleged victims were violated twice — first by Fluckiger, and then by what he termed “CDPH’s negligence.”
“You have to ask yourself, what's the tipping point in the mind of an agency like the California Department of Public Health?” asked Dark. “How many women would need to be assaulted before they felt like they needed to take action?”
CDPH did not revoke Fluckiger’s license until August 2020, more than three years after the first sexual misconduct accusation.
During that time period, Fluckiger job-hopped among at least four nursing homes, all within a few miles of each other in El Cajon and La Mesa. He was accused of either sexual misconduct, sexual assault, sodomy or rape in each of those stops.
It wasn’t until December 2020, after KPBS reported on the case of one of Fluckiger’s alleged victims, that the San Diego County District Attorney’s office charged him in three cases. He was charged with five felony counts, including four forcible lewd and lascivious conduct allegations, and remains in jail pending a trial.
Advocates and lawyers, who represent people living in senior care facilities, say there is an epidemic of sexual assaults in nursing homes. They point to CDPH’s handling of the Fluckiger case as a chilling example of the state’s indifferent oversight.
“This is just absolutely inexcusable,” said Ernest Tosh, a Texas lawyer who has sued hundreds of nursing homes alleging mistreatment of residents. “There’s no argument that had CDPH revoked the license after the first case, after the second one or even after the third one, you would not have further victimization because he would have been in the state database as an offender who cannot be hired.”
CDPH officials turned down repeated requests for an interview with KPBS. The agency also refused to answer more than two dozen questions submitted by KPBS in writing about its management of the Fluckiger investigation.
But CDPH did say in an email that it takes all complaints from nursing homes “very seriously” and “conducts comprehensive investigations to ensure any substantiated violations are immediately remedied and corrected.”
However, records show CDPH officials had several opportunities to act sooner, which the agency itself acknowledged in an August 2020 letter to Fluckiger obtained by KPBS. “Each of your actions, individually, constitutes unprofessional conduct and supports an immediate revocation of your certification,” the letter states.
Sex for cigarettes
CDPH’s first chance to stop Fluckiger came in May of 2017, records show. Employees at Parkside Health and Wellness Center in El Cajon told state investigators that Fluckiger allegedly requested oral sex from a resident in exchange for a carton of cigarettes.
The resident initially denied she had agreed to Fluckiger’s offer but later admitted she did in fact perform oral sex on him because her family didn’t give her enough money to buy cigarettes on her own.
Parkside allowed Fluckiger to continue to work at the facility for another 30 days. And when they did fire him, it wasn’t for his actions against the resident. It was for making a sexually inappropriate comment about a female co-worker, records state.
And even though CDPH knew of the cigarettes-for-oral-sex tradeoff allegation, the agency did not pull Fluckiger’s CNA license, the records show. After confirming the allegations, investigators said later only that his “actions showed a lack of dignity and respect for” the resident.
Bay Area lawyer Jennifer Fiore, who specializes in nursing home abuse lawsuits, said there was no good reason for CDPH to let Fluckiger continue working around elderly and disabled people.
“This case alone is an example of not being able to be trusted to behave appropriately in a situation where you are providing care,” Fiore said.
She says 'sodomy,' they say 'rough handling'
The records show Fluckiger didn't go far after he was fired by Parkside. In 2019, he moved just one mile away to another El Cajon nursing home, Avocado Post Acute.
A short time later, then 71-year-old Avocado resident Catherine Gotcher-Girolamo said Fluckiger pushed her face into a pillow and sodomized her with his fingers during a diaper change.
Gotcher-Girolamo, who is confined to a wheelchair because of a back injury, reported the alleged sexual assault to other caregivers and managers, who relayed her reports to investigators. Yet, CDPH still only substantiated a claim of “rough handling” by Fluckiger, the records show.
The agency refused to explain why it relied on an Avocado administrator who claimed Gotcher-Girolamo only reported rough handling during the diaper change instead of Gotcher-Girolamo’s word and that of other employees at the nursing home. And CDPH would not elaborate on how its investigators could verify the rough handling but not Gotcher-Girolamo’s sodomy allegations against Fluckiger.
What’s more, Avocado management didn’t report Gotcher-Girolamo’s allegations to the El Cajon Police Department until eight days after the alleged assault, even though the law requires every nursing home employee to notify authorities immediately of such allegations.
The police department did not refer the case to the San Diego County District Attorney’s Office until after KPBS first reported on the case in October 2020.
Kathryn Stebner, a lawyer who handles elder abuse cases, said it’s common for investigators to doubt nursing home residents — especially women — when they accuse someone of sexual assault.
”It’s very complicated,” Stebner said. “It has to do with people not believing all people. I mean it just comes down to sexism and ageism."
CDPH records show Avocado fired Fluckiger in July 2019, a month after his alleged assault on Gotcher-Girolamo. However, the reason given for his firing was not Gotcher-Girolamo’s accusation, but because Fluckiger “did not divulge on his employment application all the facilities he previously worked for,” the records show.
Within a month after he was terminated by Avocado Post Acute, Fluckiger was working as a nursing assistant one mile away at another El Cajon nursing home, San Diego Post Acute. This time he was accused of sexual assault during his first week on the job.
A resident told another caregiver that Fluckiger “pulled his pants down and went on top of me,” according to CDPH documents. The woman added that he came back in even after she said, "don't bother me."
Fluckiger denied the allegation, saying he had entered the woman’s room to change her diaper. But he quit his job at San Diego Post Acute before the CDPH investigation into the incident began.
A meeting with investigators
Fluckiger quickly got yet another job as a caregiver at a fourth nursing home five miles away in La Mesa called Parkway Hills Nursing and Rehabilitation. Two months after he started at Parkway Hills, CDPH investigators interviewed Fluckiger at a local Starbucks about the alleged sexual assault at San Diego Post Acute.
Fluckiger was visibly nervous during the questioning, shifting from side to side in his chair, the records state. He denied the sexual assault allegation and told investigators that he only gave the resident a bath because she had strong body odor and her gown and diaper were soiled.
When state investigators asked Fluckiger why he didn’t report those observations to the facility’s nursing staff instead, he said: “They’re all Filipino. They all cover up for each other. Everyone you dealt with there was Filipino. I felt discriminated against. They just didn’t like me, which is partly why I resigned.”
At one point, an investigator reminded Fluckiger that the San Diego Post Acute investigation was the third sexual allegation against him, and that as they interviewed him and others they were discovering more discrepancies in his statements.
When asked to explain why there were multiple sexual allegations against him, Fluckiger replied, “I don’t know,” the records show. He walked out of the interview after state investigators told him they had information on what happened.
But CDPH still didn’t move to revoke Fluckiger’s certification to be a nursing assistant. Less than two months later, he allegedly raped Gayle.
‘I believed him’
Gayle was admitted as a patient at Parkway Hills in December 2019 after suffering a deep cut on her leg.
During the afternoon of January 10, 2020, state investigators said Fluckiger saw Gayle vaping in Parkway’s smoking area. He approached her and asked: “What’s going on pretty girl? What are you thinking about?”
Gayle told Fluckiger she was “a bit depressed” about her life, the CDPH records state. She told him she owned a cupcake business and wanted to be a success but that she felt stuck at Parkway because of her injury.
“Oh, you’ll be alright. Besides I’m here all the time,” Fluckiger told her, according to the CDPH records. He added that he would talk to her again at around 8 p.m. during “nightly snack pass.”
Later that day after Gayle had dressed and settled into her bed to play an online game called Jewel Hunter, Fluckiger entered her room, removed her blanket, kissed her and “digitally” penetrated her, the records state.
“I grabbed him by the back of his neck and I scratched real hard and then he says, 'don’t scratch me,'” Gayle told KPBS, crying as she recalled what happened. “And then I said, 'Get away, get away' and he wouldn’t get away.”
Gayle called La Mesa police and reported that she had been raped by Fluckiger.
CDPH investigators said Fluckiger returned minutes later and digitally penetrated Gayle again. Gayle told them when she demanded that Fluckiger stop, he put his other hand on her mouth.
When he finished, Gayle said Fluckiger warned her not to report the attack and told her no one would believe her if she did.
“I believed him,” she said.
Gayle said she called the police again. When officers arrived, they took her to a local hospital to be examined.
Seven days later, a state investigator interviewed Gayle about her allegations. At one point, the investigator asked Gayle if what happened was consensual “in any way.”
“I didn’t ask for it,” she replied in a loud voice. “It’s sickening. I’m not like that …”
CDPH didn’t take away Fluckiger’s license until nearly eight months later.
An incalculable toll
One year after the alleged rape, Gayle said she remains traumatized.
“I stay awake as late as I can at night because I'm always on guard,” she said. “I always have nightmares. I feel safe when I’m in my car because it’s just a small area where nobody can get to me.”
Gayle believes she is so scarred that she will never again have a relationship with a man.
“I'm afraid when somebody looks at me, I don't want to look good,” she said. “I used to feel really pretty.”
Gotcher-Girolamo, the Avocado Post Acute resident who accused Fluckiger, told KPBS last year that memories of the alleged assault haunt her.
“I've always been a very proud woman and I'm trying to deal with this,” Gotcher-Girolamo said. ”I hurt a lot from this emotionally.”
CDPH wasn’t the only institution that could have stopped Fluckiger earlier.
The El Cajon Police Department did not arrest Fluckiger following the sexual assault allegations against him in the summer of 2019 by Gotcher-Girolamo and the woman at San Diego Post Acute.
Last year, El Cajon Lt. Keith MacArthur explained some crimes take more time to investigate.
“Sometimes, it’s better to hang on to a case to try to investigate it as much as we can,” said MacArthur. “We only get one shot at this. You don’t want to turn stuff over prematurely.”
The La Mesa Police Department also didn’t arrest Fluckiger after Gayle accused him of raping her in January 2020. In an emailed statement to KPBS, the department said detectives began working on the case as soon the report came in.
"Detectives worked closely with the San Diego County District Attorney’s Office and staff from the San Diego Sheriff’s Crime Laboratory over the next several months in an effort to build as strong of a case as possible, which ultimately involved additional cases from other jurisdictions in the county," the statement said.
Mike Dark, the nursing home advocates lawyer, said delays by both CDPH and police in the case reflect a systemic failure to protect victims of sexual assault in nursing homes.
“These women have been failed in a particularly tragic way because people who live in long-term care are extraordinarily dependent on the state and legal authorities to ensure their safety,” Dark said.
It’s a failure that has allowed sexual predators to thrive in senior care facilities, advocates say.
Tosh said that the victims and the public should not expect consequences for CDPH officials.
“No matter how inept they are, they’re going to have immunity,” Tosh said. “As a governmental department, you cannot sue them because they botched this investigation and allowed a serial rapist to run rampant. There will be no justice for their ineptitude.”
