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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604171
Report Date: 10/03/2024
Date Signed: 10/03/2024 02:54:25 PM


Document Has Been Signed on 10/03/2024 02:54 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 LIVINGFACILITY NUMBER:
374604171
ADMINISTRATOR:DUCHARME-FRANKLIN, KANDYFACILITY TYPE:
740
ADDRESS:768 DOROTHY STTELEPHONE:
(619) 444-8270
CITY:EL CAJONSTATE: CAZIP CODE:
92019
CAPACITY:68CENSUS: 64DATE:
10/03/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Business Office Manager Amanda Pepin and Clinical Director Yolanda TorresTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Iby Strong conducted an unannounced Case Management Visit to cite a deficiency which was identified during a separate complaint investigation. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Business Office Manager Amanda Pepin and Clinical Director Yolanda Torres.

On today's date, LPA Strong reviewed records. According to records reviewed, Resident 1 (R1) was assaulted by Resident 2 on September 24, 2024. According to interviews and records reviewed, licensee did not report incident to Community Care Licensing or the Long Term Care Ombudsman.

Based on records reviewed and interviews a deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D pages). An exit interview was conducted with Business Office Manager Amanda Pepin and Clinical Director Yolanda Torres. A copy of this report, the LIC 809-D pages, the LIC811 Confidential Names List pages, and the Licensee/Appeal Rights (LIC9058 03/22) were provided to her during today’s visit.

SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Iby StrongTELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 10/03/2024 02:54 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/31/2024
Section Cited
CCR
87211(c)

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(c) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours as required by Welfare and Institutions Code Section 15630(b)(1).
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Licensee agrees to provide abuse reporting AND written reporting training to all staff at facility by date and provide LPA with proof of such.
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This requirement was not met as in evidence in: Based on interviews and records reviewed the licensee did not report abuse to R1 which posed a Safety 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: 10/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2024
LIC809 (FAS) - (06/04)
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