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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604171
Report Date: 05/17/2024
Date Signed: 05/17/2024 01:52:44 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
04/09/2024 and conducted by Evaluator Iby Strong
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20240409092642
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: 56DATE:
05/17/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Executive Director Jared GreenTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Licensee did not ensure staff were trained
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 Executive Director Jared Green and discussed the purpose of the visit.-On April 9, 2024, Community Care Licensing (CCL) received a complaint licensee did not ensure staff were trained.
-During investigation, LPA Strong collected pertinent facility documentation and conducted interviews. According to allegation, multiple staff are not trained on first aid and cardiopulmonary resuscitation (CPR). Records collected revealed three out of sixteen care staff have current first aid training. Records also revealed that sixteen out of sixteen staff have CPR training. Interview with staff revealed they were unaware first aid training was not current.
-Based on records reviewed and interviews, a preponderance of evidence exists to support the allegations. Deficiencies are being cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). Additionally, a civil penalty is being issued due to duplicate citation within 12 months. An exit interview was conducted with Executive Director Jared Green to whom a copy of this report, LIC 9099-C, LIC 9099-D,421FC, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to.
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: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024
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 4
Control Number 08-AS-20240409092642
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: 05/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/29/2024
Section Cited
CCR
87411(c)(1)
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87411 Personnel Requirements(c) All RCFE staff who assist residents with personal activities of daily living ..(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
This requirement is not met as evidenced by:
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Licensee agrees to provide training to care staff, will provide proof of training to LPA.
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Based on records reviewed the licensee did not provide first aid training to 13 of 16 staff which poses a potential health and safety risk to 56 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: 05/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
04/09/2024 and conducted by Evaluator Iby Strong
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20240409092642

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: 56DATE:
05/17/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Executive Director Jared GreenTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Licensee did not reassess residents
Staff did not provide a safe environment
Staff did not prevent residents from smoking in non-smoking areas of facility.
Staff did not maintain facility in good repair.
Staff did not maintain a comfortable temperature for residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to deliver findings in the above-mentioned allegations. LPA identified herself and discussed the purpose of the visit with Executive Director Jared Green.
On April 9, 2024, Community Care Licensing (CCL) received a complaint alleging licensee did not reassess residents, staff did not provide a safe environment, staff did not prevent residents from smoking in non-smoking areas of facility, staff did not maintain facility in good repair, and staff did not maintain a comfortable temperature for residents.

According to allegation, since November of 2023, Resident 1 (R1), Resident 2 (R2) and Resident 3 (R3), had not been reassessed after new threatening behaviors developed. Records collected revealed that such behaviors were documented prior to November 2023. Interviews with staff revealed that R1, R2 and R3, all have behaviors that staff have been trained to intervene in. Interview with outside source established that residents are reassessed annually and there is no concern for residents in care.

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: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 08-AS-20240409092642
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: 05/17/2024
NARRATIVE
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It was also alleged that staff did not provide residents with a safe environment from R1, R2 and R3. Interviews with staff revealed that such residents had not had behaviors that injured any of the other residents. Records reviewed did not reveal any information to corroborate that these residents had had threatening behaviors. Outside source interviews did not reveal any corroborating information.

Additionally, it was alleged that staff did not prevent residents from smoking in non-smoking areas of facility. Interview with staff revealed that residents have been found smoking in the non-smoking areas of the facility. Staff revealed that residents are reminded of smoking areas, but they cannot be physically forced them to move. Interviews with residents revealed that residents are often reminded where smoking areas are.

Also, it was alleged that facility had mold in the vents and walls were damaged. On May 8, 2024, LPA Strong conducted a facility inspection and did not observe any damaged walls or mold in the vents. Interview with Maintenance Director revealed that maintenance workers are continuously working on the facility. Interview with staff did not reveal any information to corroborate this allegation.

Lastly, it was alleged that facility staff did not maintain a comfortable temperature for residents. On May 8, 2024, LPA Strong also reviewed the facility temperatures, noting that the indoor temperatures for the main lodge was 70 degrees Fahrenheit and each cottage ranged from 70-75 degrees Fahrenheit. Interview with Maintenance Director revealed that they can control the facilities temperatures via mobile device. Interviews with outside sources did not reveal any information to corroborate allegation.

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 Executive Director Jared Green, 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: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4