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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604171
Report Date: 07/26/2023
Date Signed: 07/26/2023 04:08:52 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
05/11/2023 and conducted by Evaluator Iby Strong
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20230511103922
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: 58DATE:
07/26/2023
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Wellness Coordinator Jenna PurnellTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Licensee did not report change in condition
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Iby Strong conducted an unannounced complaint visit to deliver findings in the above-mentioned allegation. LPA met with Wellness Coordinator Jenna Purnell and discussed the purpose of the visit.
On May 11, 2023, Community Care Licensing (CCL) received a complaint alleging licensee did not report change in medical condition to Resident 1 (R1) and Resident 2 (R2).

During investigation, LPA Strong collected pertinent resident records as well as facility documentation and conducted interviews. According to allegations, on May 10, 2023, R1 arrived at their medical appointment with a change in medical condition that was not previously reported to medical provider. Medical records collected for R1 revealed that medical provider was not previously notified of R1’s change in mental and physical functions as such that R1 was unable to maintain upright posture which was different than their baseline. Interview with outside source revealed that there was no communication between licensee and medical provider regarding observed changes in R1.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Iby StrongTELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023
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-20230511103922
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: LO-HAR SENIOR LIVING
FACILITY NUMBER: 374604171
VISIT DATE: 07/26/2023
NARRATIVE
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Continued from LIC-9099

Additionally, it was alleged that on May 11, 2023, R2 arrived at their medical appointment with an injury that was not previously reported to medical provider. Medical records collected for R2 revealed that R2 arrived at medical appointment with left eye swelling and bruising, medical notes state facility was contacted and facility staff communicated awareness of injury but was unsure how injury occurred. Interview with facility staff revealed that R2 had a bruise on left side of face as of May 6, 2023. Interviews with staff also established that it was unsure if facility had reported change in condition to medical provider. Interview with outside source revealed that a healing bruise was seen on R2 as of May 8, 2023.

Based on interviews, and records reviewed, a preponderance of evidence exists to support the allegations. A deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). An exit interview was conducted with Wellness Coordinator Jenna Purnell, to whom a copy of this report, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to.

SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Iby StrongTELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20230511103922
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: LO-HAR SENIOR LIVING
FACILITY NUMBER: 374604171
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/09/2023
Section Cited
CCR
87466
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87466 When changes such as..deterioration of mental ability or a physical health condition are observed... licensee shall ensure that changes are... brought to the attention of the resident's physician. This requirement was not met as evidenced by:
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Wellness Director has implemented a new reporting system for all staff and will provide documentation to new system to LPA Strong by 8/9/2023.
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Based on records reviewed and interviews, the licensee did not report metal or physical health conditions in 2 of 56 persons in care ([R1/R2]) which posed a potential Health 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: Simon JacobTELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Iby StrongTELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023
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
SAN DIEGO RO, 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
05/11/2023 and conducted by Evaluator Iby Strong
COMPLAINT CONTROL NUMBER: 08-AS-20230511103922

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: DATE:
07/26/2023
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Wellness Coordinator Jenna PurnellTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Neglect resulted in a pressure injury
Neglect resulted in multiple injuries
Facility staff restrained resident
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 May 11, 2023, Community Care Licensing (CCL) received a complaint alleging facility neglect to Resident 1 (R1)resulted in pressure injury, facility neglect to R1 resulted in multiple injuries and facility staff restrained R1.

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 August 4, 2022, R1 is diagnosed with a major neurocognitive disorder, has no history of skin condition or breakdown and is nonverbal. According to allegation, R1 was neglected which resulted in pressure injury. Medical records collected revealed that R1 was diagnosed with a stage 2 pressure injury to left ischial tuberosity on May 10, 2023. Records revealed resident has no history of pressure injuries.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Iby StrongTELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2023
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-20230511103922
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: LO-HAR SENIOR LIVING
FACILITY NUMBER: 374604171
VISIT DATE: 07/26/2023
NARRATIVE
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Continued from LIC9099-A

Records also revealed that as of May 17, 2023, same stage 2 pressure injury to left ischial tuberosity had healed. Additional records revealed that on May 17, 2023, another stage 2 pressure injury to the coccyx was found. Records also established that as of May 24, 2023, stage 2 pressure injury to coccyx had healed. Interviews also revealed that R1 is bathed two times a week with skin checks and no skin issues had been noted by staff.

It was also alleged that R1 was found to have multiple minor injuries throughout their body due to neglect. Medical records collected revealed that R1 was found to have fluid filled blister on the palm of the left hand; a shallow linear light pink abrasion to the right forearm and a light blue- green bruise to inside of left knee. Interview with Administrator revealed that R1 tends to scratch self with nails, leaving small scratches on their arm. Administrator also revealed that blisters would commonly appear on R1’s hands and they had been reported to physician. Interview with staff revealed that there was no known cause to R1’s bruise to the inside of the knee. Interview with outside source revealed no issues with R1’s care at facility.

Lastly, it was alleged that R1 was restrained to wheelchair by facility staff. Interviews with staff present on the date of the incident revealed that no staff used wheelchair seatbelt on R1. During investigation, there was no other corroborating evidence to show R1 was restrained to wheelchair by facility staff.

Based on LPA's interviews, and record reviews there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegation is 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: Simon JacobTELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Iby StrongTELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5