374604171-11-21-2022-08-AS-IESA-CLP5UU-20221130191632

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604171
Report Date: 11/21/2022
Date Signed: 11/21/2022 10:22:05 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
11/01/2021 and conducted by Evaluator Rebecca A Ruiz

COMPLAINT CONTROL NUMBER: 08-AS-20211101095744

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: 58	DATE:	11/21/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Jenna Purnell		TIME COMPLETED:	10:25 AM

ALLEGATION(S):

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Staff did not protect resident resulting in fractured ribs
Licensee did not report resident's change in condition to responsible party

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced complaint investigation visit to deliver findings regarding the above-mentioned allegations. LPA identified herself to, was greeted by, and explained the purpose of the visit to Wellness Coordinator Jenna Purnell.

The Department’s investigation consisted of interviews with staff, residents, and outside sources, records review, and a tour of the facility. It was alleged that staff did not protect resident resulting in fractured ribs and the Licensee did not report resident’s change in condition to their responsible party. Review of resident 1’s (R1) medical records revealed that R1 was non-ambulatory, required a walker, had a diagnosis of dementia with behavioral disturbance and agitation, and had a history of confusion, disorientation, and aggressive behaviors. Interviews revealed that on October 30, 2021 at around 12:00am, Staff 1 (S1) heard R1 and resident 2 (R2) verbally arguing requiring staff to redirect both residents. At around 3:00am, staff observed R1 sitting on a couch with blood under R1’s nose and R1’s walker was not nearby.
Continued on LIC9099-C page...

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2022

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 3

Control Number 08-AS-20211101095744

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: LO-HAR SENIOR LIVING	FACILITY NUMBER: 374604171
	VISIT DATE: 11/21/2022

NARRATIVE

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When staff asked R1 what happened, R1 stated “that animal” hit R1. S1 cleaned up the blood, assisted R1 back to their room, and observed R1’s walker in the room. S1 conducted their rounds on residents and observed that R2 was awake. S1 checked R2 for any injuries and did not find any injuries on R2 that may be indicative of R2 hitting R1. S1 called the facility’s Executive Director to notify her of the incident with R1. S1 stated that they did not notify R1’s responsible party of the incident due to not having a fluent Spanish speaking staff on duty at the time. S1 stated that S1 did not call for an ambulance because R1’s injury did not show any signs of needing to go to the hospital. Staff stated R1 and R2 slept for the rest of the night without further incidents.

At around 7:15am on October 30, 2021, staff 2 (S2) started their shift and observed R1 moving slowly, had dried blood on R1’s nose, and R1 was complaining of pain. When S2 asked R1 what happened, R1 stated a resident punched R1 in the face, causing R1 to fall on the floor and then that resident started kicking R1. R1 stated that they did not tell anyone about the attack at that time. At 8:00am, S2 observed R1 looking pale and asked R1 who hit them and R1 pointed to R2. Interviews revealed that staff called R1’s granddaughter in the morning of October 30, 2021 to explain the incident between R1 and R2 and requesting to transfer R1 to the hospital because R1 was complaining of pain. R1’s granddaughter placed the phone call on speaker phone so staff could also speak to R1’s son. R1’s son spoke to R1 and agreed to have R1 sent to the hospital for evaluation. After R1’s condition did not improve after breakfast, staff called an ambulance for R1 at 9:00am. Review of R1’s hospital medical records revealed that R1 had two pre-existing rib fractures and did not have any bruising noted on R1’s back or abdomen. Interviews with R1’s family revealed that on October 30, 2021, hospital staff informed them that they were unable to determine when the fractures occurred and that there was no bruising to indicate the fractures occurred recently. R1’s family stated that R1 had fallen at the facility in the past and bruised easily. R1’s family checked R1’s body and did not observe any bruises so they did not think that R1 had been in a fight.

Continued on LIC9099-C page...

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 08-AS-20211101095744

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: LO-HAR SENIOR LIVING	FACILITY NUMBER: 374604171
	VISIT DATE: 11/21/2022

NARRATIVE

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Interviews with staff and review of R2’s progress notes revealed that R2 had a history of trying to assist other residents like a staff member and had started guarding the bathroom by standing in front of it and pacing. R2’s progress notes revealed that R2 did not have aggressive behaviors upon move in and became aggressive around August 2021. On August 3, 2021, R2 was admitted to the hospital for evaluation after being observed raising a hand to strike another resident. R2 returned to the facility on August 17, 2021. On September 3, 2021, R2 began taking medication for aggressive behaviors and was being monitored by staff.

The Department has investigated the above-mentioned allegations and based on interviews and records review, the preponderance of the evidence has not been met, therefore, these allegations are deemed unsubstantiated.

An exit interview was conducted with Wellness Coordinator Jenna Purnell, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 01/16) were provided via hard copy.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2022

LIC9099 (FAS) - (06/04)

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