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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604171
Report Date: 07/05/2023
Date Signed: 07/05/2023 05:48:56 PM


Document Has Been Signed on 07/05/2023 05:48 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 LIVINGFACILITY NUMBER:
374604171
ADMINISTRATOR:DUCHARME-FRANKLIN, KANDYFACILITY TYPE:
740
ADDRESS:768 DOROTHY STTELEPHONE:
(619) 444-8270
CITY:EL CAJONSTATE: CAZIP CODE:
92019
CAPACITY:68CENSUS: 55DATE:
07/05/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Manager Itzayana Barba and Wellness Coordinator Jenna PurnellTIME COMPLETED:
06:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Manager Itzayana Barba and Wellness Coordinator Jenna Purnell.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 06/21/2023). According to the LIC624: on 06/12/2023, Resident #1 (R1) eloped from the facility (left without staff supervision). [See LIC 811 Confidential Names List for a description of R1.] R1 was returned to the facility later the same day, unharmed/uninjured.

During today’s visit, LPA performed a facility tour / welfare check, verifying that R1 was indeed unharmed/uninjured. LPA also inspected the facility’s perimeter gates and tested their ability to self-close and latch. LPA then reviewed pertinent care and administrative records and interviewed relevant staff.

According to their latest LIC602 Physician’s Report (dated 04/19/2022), R1 was diagnosed with “Senile Dementia” and their doctor determined that they were not able to safely leave the facility unassisted. According to the latest LIC603A Resident Appraisal (dated 03/24/2023), which Licensee performed on R1, they were described as “forgetful, confused, wanderer.” According to the latest Care Plan on R1, which Licensee authored for staff use, R1 was required to be “visually checked on frequently through the day and night to promote safety…”

Based on records reviewed and staff interview: R1 resided in the facility’s memory care section, had a pattern of loitering near the facility’s locked perimeter gates (near the front of the facility), but was otherwise able tob be redirected by staff. Per management interview, R1 needed staff escort whenever they were outdoors, even if they remained on the facility yard/grounds. However, during the 06/12/2023 incident, staff did not witness R1’s elopement and were initially unaware that they were missing. R1 was located by a member of the public, who brought R1 back to the facility, unharmed. [CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/05/2023
NARRATIVE
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[CONTINUED FROM LIC 809] Following R1’s return, staff discovered that a perimeter gate near the front of the facility’s main memory care building was not fully self-closing and latching, after being opened. The gate in question was repaired on 06/13/2023. A preponderance of evidence exists to show that Licensee did not provide needed observation to R1, which was material to R1’s elopement incident.

During today’s visit, LPA observed that the facility’s memory care buildings utilized a “secured perimeter,” meaning that the perimeter exits and gates are locked from both the inside and the outside. Per review of the facility’s license from CCLD, and the facility’s latest Fire Clearance (dated 12-06-2019): the facility did not have prior approval/endorsement from the State Fire Marshall, or from CCLD, for use of a “secured perimeter.”

Based on record review, and corroborated by manager interview: Licensee did not possess an LIC602 Physician’s Report (or equivalent medical assessment) on R1 which had been updated within the last year, as is required for residents who are diagnosed with a dementia (as is the case with R1).

Deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC809-D pages). CCLD determined one of these violations resulted in the facility not complying with its approved Fire Clearance from the local fire authority. An immediate Civil Penalty of $500.00 is thus charged and is noted on the LIC421-IM.

LPA issued a Technical Violation (TV) regarding reporting requirements/timelines. LPA also issued Technical Assistance (TA) regarding a self-closing mechanism on one of the facility’s perimeter gates in its assisted living section (which was not a contributing factor to R1’s elopement incident).

An exit interview was conducted with Purnell, to whom a copy of this report, the LIC809-D pages, the LIC9102-TV, the LIC9102-TA, the LIC421-IM, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 07/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 07/05/2023 05:48 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/06/2023
Section Cited
CCR
87705(l)(2)

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87705 Care of Persons with Dementia: “(l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (2) The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates.”
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By the POC due date, Licensee agreed to E-mail to the CCLD San Diego Regional Office’s (RO's) main intake E-mail address, and to cc’ LPA: a) an LIC200 Application which indicates a request for use of secured perimeter, and b) a Waiver Request from Regulation 87468(a)(6), to prevent residents from leaving the facility. These actions will prompt the RO to request a subsequent fire authority re-inspection for the facility.
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This requirement was not met, as evidenced by: Based on observation, in areas of the facility where 30 of 55 residents (R1 through R30) resided, licensee locked exterior doors and perimeter fence gates, but did not ensure that its fire clearance included approval of locked exterior doors or locked perimeter fence gates, which posed an immediate safety risk to persons in care.
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Type B
08/04/2023
Section Cited
CCR87466

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87466 Observation of the Resident: “The licensee shall ensure that residents are regularly observed…” This requirement was not met, as evidenced by:
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Licensee agreed to formally retrain its direct care staff at large (to include both facility staff and outside agency caregivers), teaching that: a) all memory-impaired residents must be accompanied by staff when outdoors, and b) staff must ensure that the facility’s perimeter doors and gates fully close and latch after being opened.
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Based on records and interviews, the licensee did not ensure that 1 of 55 residents (R1) was observed, which posed a potential safety risk to persons in care.
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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: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 07/05/2023 05:48 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/04/2023
Section Cited
CCR
87705(c)(5)

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87705 Care of Persons with Dementia: “(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.”
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Licensee agreed to coordinate with R1’s physician, responsible party, and/or case manager, as needed, to obtain a new/updated LIC602 Physician’s Report for R1, and to place it in R1’s resident file. Licensee agreed to mark their internal calendar to remind them that for every resident diagnosed with dementia, Licensee will need to facilitate a new LIC602 within the next 12 months. Licensee agreed to E-mail LPA a copy of R1’s new/updated LIC602, by the POC due date.
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This requirement was not met, as evidenced by: Based on records and interviews, licensee did not ensure that 1 of 55 residents (R1), who was diagnosed with a dementia, had a medical assessment performed within the last year, which posed a potential health, safety, and personal rights risk to persons in care.
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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: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4