374604171-1-5-2024-08-AS-IESA-CZZUJ8-20240131143708

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604171
Report Date: 01/05/2024
Date Signed: 01/05/2024 02:58:06 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
07/12/2021 and conducted by Evaluator Becky Kennedy

COMPLAINT CONTROL NUMBER: 08-AS-20210712083444

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: 40	DATE:	01/05/2024
		UNANNOUNCED	TIME BEGAN:	02:35 PM
MET WITH:	Karriem Jones		TIME COMPLETED:	03:19 PM

ALLEGATION(S):

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Lack of supervision resulting in serious bodily injury
Facility staffing is insufficient to meet resident's needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst Becky Kennedy concluded the investigation which began on 7/14/2021. LPA Kennedy made an unannounced visit to the above facility today and met with MedTech, Karriem Jones. LPA advised Mr. Jones of the reason for today's visit and delivered the investigation findings on the above allegations.

It was alleged that a lack of supervision resulted in serious bodily injury to Resident 1 (R1), and that the facility staffing was insufficient to meet the resident’s needs.

The investigation into the above allegations consisted of observations, interviews with residents, staff, outside sources, records reviews, and tour of the interior and exterior facility. The investigation revealed that on 4-2-2021 R1 was in the dining area of the facility and got up from their wheelchair holding a bowl. As R1 attempted to walk across the dining room R1 fell.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Icela Estrada	TELEPHONE: (619) 688-6866
LICENSING EVALUATOR NAME: Becky Kennedy	TELEPHONE: 619-672-5843
LICENSING EVALUATOR SIGNATURE:	DATE: 01/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024

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-20210712083444

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: 01/05/2024

NARRATIVE

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Two caregivers were in the dining room at the time of R1’s fall, and two additional staff members responded to assess R1. Facility staff called 911 as R1 reported being in pain. R1 was taken by ambulance to the hospital where R1 was diagnosed with a hip fracture.

Interviews with R1, staff and outside sources revealed that R1 is prone to falls due to both a medical condition and a temperament such that R1 is resistant to efforts intended to discourage R1 from attempting to walk and other fall mitigation efforts. The facility provided R1 with a pendant to alert staff when they need assistance and fall alert mats were placed near R1’s bed and chair. R1 lost the pendant and disabled the fall alert mats. Due to R1’s vulnerability to falling, staff member check on R1 every 30 minutes.

Staffing the facility has been a concern since the COVID-19 pandemic. The facility had ongoing hiring efforts to replace staff that resigned. Although at the time of the incident staffing was not at pre-pandemic levels, interviews with staff and outside sources revealed that staff worked hard to meet all resident’s needs.
R1’s fall was not due to either inadequate staffing or a lack of care and supervision.

Based on observation and statements from internal and external sources including R1, the investigative findings are unsubstantiated. An exit interview was conducted and a copy of this report, and appeal rights were given to Karriem Jones.

SUPERVISOR'S NAME: Icela Estrada	TELEPHONE: (619) 688-6866
LICENSING EVALUATOR NAME: Becky Kennedy	TELEPHONE: 619-672-5843
LICENSING EVALUATOR SIGNATURE:	DATE: 01/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024

LIC9099 (FAS) - (06/04)

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