374604171-9-27-2023-08-AS-SJAB-CW4TZV-20230928151057

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604171
Report Date: 09/27/2023
Date Signed: 09/27/2023 03:55:55 PM

Unsubstantiated

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
09/12/2023 and conducted by Evaluator Iby Strong

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20230912164202

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: 64	DATE:	09/27/2023
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Wellness Director Jenna Purnell		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Neglect resulted in resident suffering a medical emergency
Resident's medical records were not maintained
Staff did not provide a resident with a bed

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to continue an investigation on the above mentioned complaint allegations. LPA identified herself and discussed the purpose of the visit with Executive Director Jared Green and Wellness Director Jenna Purnell.

On September 12, 2023, Community Care Licensing (CCL) received a complaint alleging neglect resulted in Resident 1 (R1) suffering a medical emergency, Resident 2 (R2) records were not maintained and staff did not provide R2 with a bed.

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 11, 2023, R1 is diagnosed with a major neurocognitive disorder, is confused and disoriented but is able to follow instructions and communicate needs.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Iby Strong	TELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023

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-20230912164202

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: 09/27/2023

NARRATIVE

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According to allegation, R1’s was left outside of facility and due to such neglect suffered a medical emergency. Interview with Wellness Director revealed that on the date of incident R1 was sitting outside on memory care porch when R1 stated they did not want to come inside. Wellness Director indicated assessing resident multiple times and each time R1 was at baseline. According to the interview, one hour later R1 was slouching down, no longer at baseline and emergency personnel were contacted. Interview with staff present on the date of the incident corroborated that R1 was assessed multiple times prior to incident. Records collected revealed that on September 9, 2022, R1 was taken to emergency room by paramedics and was diagnosed with a urinary tract infection. Records collected did not reveal any information that indicated neglect of resident. Outside source interview revealed that R1 prefers to sit outside on facility porch and will chose to stay outside for long periods of time. Outside source also revealed that they have no issues with care being provided to R1 by facility staff and have seen no indication of resident neglect.

It was also alleged that R2’s medical records were not maintained accurately. During investigation, LPA reviewed R2’s records and observed physicians report, resident plan of care and multiple medical records including medication prescriptions. Interview with outside source did not reveal any documentation missing or inaccurate. Interview with Wellness Director did not corroborate R2’s records were not maintained.

Lastly, it was alleged that R2 was not afforded a bed to sleep on. According to R2’s Physician Report signed July 13, 2023, R2 can leave facility unassisted and can communicate needs. Additionally, R2 records collected revealed that R2 has had recent increases of agitation towards staff and roommates. During investigation LPA Strong observed R2’s assigned room within assisted living with a bed, television, night stand, lamp, and personal belongings. Interview with R2 revealed that R2 is sleeping on wheelchair in the memory care cottage living room by choice and is refusing to use bed in assigned room. According to interview with R2, bed in assigned room is not comfortable for their personal needs. Interview with outside source revealed that R2 was scheduled to move out of this facility on September 26, 2023, but declined new facility and chose to stay at current facility. Interview with Executive Director revealed R2 chooses to sleep in wheelchair and R2 has declined three other room options. Records also did not reveal any special bed prescribed to R2 by the medical provider.
Based on LPA's interviews, observations and record reviews there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with Wellness Director Jenna Purnell, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Iby Strong	TELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023

LIC9099 (FAS) - (06/04)

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