374604171-12-14-2023-08-AS-SJAB-CYWUZ7-20231227150104

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604171
Report Date: 12/12/2023
Date Signed: 12/14/2023 09:12:05 AM

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
11/14/2023 and conducted by Evaluator Iby Strong

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20231114135318

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: 63	DATE:	12/12/2023
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Wellness Director Jenna Purnell		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff neglect resulted in a resident sustaining a bedsore
Staff did not provide a resident with an appropriate living arrangement
Staff did not prevent a resident from causing harm to another resident
Staff did not properly report an incident involving a resident

INVESTIGATION FINDINGS:

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

On November 14, 2023, Community Care Licensing (CCL) received a complaint alleging neglect to Resident 1 (R1) resulted in R1 sustaining a bedsore, staff did not provide Resident 2 (R2) with an appropriate living arrangement, staff did not prevent Resident 3 (R3) from causing harm to Resident 4 (R4) and Staff did not properly report an incident to R4’s responsible party.

During the investigation, LPA Strong collected pertinent resident records as well as facility documentation and conducted interviews. Based on Resident 1 (R1) Physician’s Report dated October 27, 2022, R1 is confused/disoriented and is non-ambulatory. According to interviews with staff, R1 is actively receiving Home Health visits for Stage II pressure ulcer.

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: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

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-20231114135318

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: 12/12/2023

NARRATIVE

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Interview with outside source verified that R1 is receiving such care. Interview with outside source also revealed that they did not believe that R1 was neglected, rather that the facility established wound care with medical provider in a timely manner. Records and interviewed also revealed that R1 Stage II pressure ulcer has healed due to proper care of wound.

It was also alleged that R2 was forced to sleep on the living room couch and their bed was given to another resident. Interview with staff revealed that R2 preferred to sleep on living room couch and multiple staff attempts to redirect resident but resulted in resident returning to couch. Interviews also revealed R2’s bed was not given to another resident, rather, another resident slept in R2’s bed when it was not in use. Interview with outside source revealed that R2 was given the right to a safe and comfortable accommodation.

Additionally, it was alleged that staff did not prevent R3 from harming R4. According to interviews with Staff 1 (S1) and Staff 2 (S2) on November 2, 2023, staff observed R3 having an emotional outburst that resulted in R4 being pushed by R3 and R4 sustaining a skin tear on the back of the hand. Interviews also revealed R4 was given first aid. Interview with outside source established that there were no concerns regarding the supervision and care of R3 as well as R4 are receiving.

Lastly, it was alleged that R4’s responsible party was not notified of R4’s injury after altercation with R3. According to S2, S2 contacted the responsible party by telephone on the date of the incident. LPA Strong also observed a signed incident report created by S2 that documented S2 contacting the reporting party. Interview with outside source established that responsible party did not receive a phone call regarding such incident.

Based on LPA's interviews, observations, record reviews and conflicting statements there is not a preponderance of evidence to prove alleged violation 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: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

LIC9099 (FAS) - (06/04)

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