374604171-2-28-2023-08-AS-JRAE-CPGUQL-20230228144719

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604171
Report Date: 02/27/2023
Date Signed: 02/28/2023 10:03:29 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/13/2022 and conducted by Evaluator Iby Strong

COMPLAINT CONTROL NUMBER: 08-AS-20220613103313

FACILITY NAME:	LO-HAR SENIOR LIVING		FACILITY NUMBER:	374604171
ADMINISTRATOR:	DUCHARME-FRANKLIN, KANDY		FACILITY TYPE:	740
ADDRESS:	768 DOROTHY ST		TELEPHONE:	(619) 444-8270
CITY:	EL CAJON	STATE: CA	ZIP CODE:	92019
CAPACITY:	68	CENSUS: 57	DATE:	02/27/2023
		UNANNOUNCED	TIME BEGAN:	04:08 PM
MET WITH:	Wellness Coordinator Jenna Purnell		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff did not prevent a resident from wandering away from facility.
Staff did not address a resident's change in medical condition

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to deliver findings in the above complaint allegations. LPA identified herself and discussed the purpose of the visit with Wellness Coordinator Jenna Purnell.

On June 13, 2022, Community Care Licensing (CCL) received a complaint alleging staff did not prevent a resident from wandering away from facility, and staff did not address a resident's change in medical condition. Additional information was received by CCL on December 19, 2022, regarding staff not preventing the same resident from wandering away from facility on another date.

During investigation, LPA Strong collected pertinent resident records as well as facility documentation and conducted interviews. Based on Resident 1 (R1) Physician’s Report dated July 7, 2022, R1 is diagnosed with mild cognitive impairment, is confused and disoriented, does not require continuous care, cannot leave facility unassisted and has wandering behavior.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: John Rante	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Iby Strong	TELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20220613103313

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: LO-HAR SENIOR LIVING	FACILITY NUMBER: 374604171
	VISIT DATE: 02/27/2023

NARRATIVE

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R1’s Individual Care Plan signed March 28, 2022, revealed R1 is independent with toileting and eating, is forgetful, and requires frequent checks throughout the day and night. According to allegations, R1 wandered away from facility on June 11, 2022, was found by police in a foreign home, and was admitted to the hospital for observation. Records revealed that R1 was last seen on June 11, 2022, at 1:30pm, while R1 was smoking a cigarette in a facility common area. Interview with staff present on the date of the incident revealed that R1 was not found during 8:00pm medication administration rounds. Staff stated R1 was searched for in and around the facility, Administrator was then contacted who instructed staff to call 911 and responsible party. Records collected corroborated that emergency personnel arrived at the facility at 10:34pm on date of incident. Interview with outside source established that responsible party was contacted on the night of the incident. Review of facility’s absentee notification plan revealed that facility followed all procedures during the incident in question.

It was also alleged that facility allowed R1 to wander away from facility on December 17, 2022. According to interview with staff present on the date of the incident, R1 was last seen during shift change at 1:30pm in the gated outdoor area. Interview with staff established that R1 was not found during dinner service and staff initiated a search for R1. Records collected revealed that emergency personnel arrived at facility to collect a report on the same day of incident. Interview with outside source revealed that after first incident of resident leaving facility unassisted on June 11, 2022, R1 was moved to the memory care cottage. Interview with Administrator revealed that R1 reached over memory care locked patio gate and walked out. Interview with outside source corroborated that responsible party was contacted immediately after resident was not found. Review of facility’s absentee notification plan revealed that facility followed all procedures during the second incident in question. Lastly, an updated Physician’s Report dated July 20, 2022, revealed R1 is allowed to leave facility unassisted.

It was also alleged that staff did not address R1’s change in condition prior to June 11, 2022, to prevent R1 from wandering away from the facility. According to allegation, Staff 1 (S1) was contacted by telephone after R1 was found wandering on June 11, 2022. It was alleged that during this telephone call, S1 stated R1 had a history of wandering away from the facility. Interview with S1 revealed that S1 could not recall stating the incident on June 11, 2022, was R1’s second time wandering away from facility. Interview with Administrator revealed that R1 had not had a change in condition prior to June 11, 2022.

SUPERVISOR'S NAME: John Rante	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Iby Strong	TELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2023

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20220613103313

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: LO-HAR SENIOR LIVING	FACILITY NUMBER: 374604171
	VISIT DATE: 02/27/2023

NARRATIVE

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Records collected corroborated that no change in condition was documented between R1’s move-in date of August 1, 2021, and date of first wandering incident of June 11, 2022. Interview with outside source revealed that after R1’s first wandering incident on June 11, 2022, R1’s responsible party communicated wandering event to R1’s medical provider, and R1 was moved into the memory care cottage for additional assistance.

Based on LPA's interviews with staff, outside source interviews, and record reviews there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegations are unsubstantiated. An exit interview was conducted with Wellness Coordinator Jenna Purnell, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.

SUPERVISOR'S NAME: John Rante	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Iby Strong	TELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2023

LIC9099 (FAS) - (06/04)

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