374604171-4-28-2023-08-AS-DPOL-CSCTDB-20230531143804

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604171
Report Date: 04/28/2023
Date Signed: 04/28/2023 08:19:56 PM

Substantiated

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
04/26/2023 and conducted by Evaluator Marisela Garcia-Centeno

COMPLAINT CONTROL NUMBER: 08-AS-20230426115034

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: 56	DATE:	04/28/2023
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Wellness Coordinator, Jenna Purnell		TIME COMPLETED:	06:30 PM

ALLEGATION(S):

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Staff did not provide residents clean linens on a weekly basis

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Marisela Garcia-Centeno made an unannounced visit to open an investigation and deliver findings on the above-mentioned allegation. LPA identified herself and disclosed the purpose of her visit. LPA met with Wellness Director, Amy Castillo and Administrator, Ducharme-Franklin, Kandy and discussed the basic elements of the complaint.

The Department investigated the above listed complaint allegation. The investigation consisted of a tour of the facility and multiple interviews with residents and staff.

On April 26, 2023, Community Care Licensing (CCL) received a complaint alleging that staff did not provide residents clean linens on a weekly basis. During a visit conducted on April 28, 2023, the linens for five (5) residents were observed with stains and were heavily soiled with what appeared to be bodily fluids. The mattress pads and sheets were observed to be wet and had urine smell. During interviews with residents, it was indicated that their linens had not been changed for several weeks.
(Continue on LIC9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: John Rante	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno	TELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

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

LIC9099 (FAS) - (06/04)

Page: 1 of 5

Control Number 08-AS-20230426115034

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: 04/28/2023

NARRATIVE

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(Continue from LIC9099)

The residents stated that the bed linen was supposed to be changed once a week the same day as their showers schedules but that it had not been the case for several months. During interviews, staff indicated the linen should be changed once a week or more often as needed. However, due to staffing shortages the laundry had been delayed. Based on observations and the information obtained during interviews with residents and staff it was determined that staff did not provide clean linen once a week as required. Therefore, this allegation is deemed to be substantiated. A substantiated finding means the allegation is valid because the preponderance of the evidence standard has been met. A deficiency was cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations and is listed on LIC 9099-D. A plan of corrections was developed with Administrator, Ducharme-Franklin Kandy.

An exit interview was conducted with Administrator, Ducharme-Franklin and a copy of this report, Deficiency Report LIC9099D, along with Licensee/Appeal Rights (LIC 9058 03/22) were provided at the conclusion of the visit.

SUPERVISOR'S NAME: John Rante	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno	TELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 08-AS-20230426115034

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/28/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/19/2023 Section Cited CCR 87307(3)(C)	1 2 3 4 5 6 7	Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets…The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator agreed to provide in service training for all current and new staff. Administrator is in the process of hiring new staf to bring staffing levels up to the numbers sufficient to meet the needs of the residents.
	8 9 10 11 12 13 14	Based on observations and interviews, the licensee did not provide clean linen to residents on a weekly basis. This posed a potential health and personal rights risk to 56 of 56 residents in care.	8 9 10 11 12 13 14	Documentation of training and updated staffing plans will be submitted to CCL by POC date of 5/19/2023.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: John Rante	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno	TELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
04/26/2023 and conducted by Evaluator Marisela Garcia-Centeno

COMPLAINT CONTROL NUMBER: 08-AS-20230426115034

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: 56	DATE:	04/28/2023
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Wellness Coordinator, Jenna Purnell		TIME COMPLETED:	06:30 PM

ALLEGATION(S):

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Staff disposed of residents' personal property

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Marisela Garcia-Centeno made an unannounced visit to open an investigation and deliver findings on the above-mentioned allegation. LPA identified herself and disclosed the purpose of her visit. LPA met with Wellness Director, Amy Castillo and Administrator, Ducharme-Franklin, Kandy and discussed the basic elements of the complaint.

The Department investigated the above listed complaint allegation. The investigation consisted of a tour of the facility and multiple interviews with residents and staff.

On April 26, 2023, Community Care Licensing (CCL) received a complaint alleging that staff disposed of residents' personal property. It was specifically alleged that staff disposed of a resident’s motorized wheelchair. During a visit conducted on April 28, 2023, the motorized wheelchair was observed in the facility. Interviews with staff indicated the wheelchair had been moved to a different location of the facility. (Continue on LIC9099C

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: John Rante	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno	TELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

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

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 08-AS-20230426115034

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: 04/28/2023

NARRATIVE

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(Continue from LIC9099A)

From the information obtained during interviews with staff, it was assumed the wheelchair had been disposed of due to a miscommunication situation. During the visit, the wheelchair was returned to its original location.

Based on the results of the investigation, which consisted of observations, interviews with key witnesses there was no evidence found to support this allegation. The Department has found that the complaint allegation was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted with Administrator, Ducharme-Franklin and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 03/22) were provided at the conclusion of the visit.

SUPERVISOR'S NAME: John Rante	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno	TELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5