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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604171
Report Date: 10/05/2026
Date Signed: 10/05/2026 10:41:39 AM

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
04/07/2021 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20210407163840
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: 65DATE:
10/05/2026
UNANNOUNCEDTIME BEGAN:
09:47 AM
MET WITH:Jenna Purnell, Wellness CoordinatorTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Facility staff neglected resident resulting in severely infected multiple pressure injuries.
INVESTIGATION FINDINGS:
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On 10/5/2026, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced investigation visit to deliver the investigation finding and met with Jenna Purnell and explained the purpose of the visit.

On April 7, 2021 the Department received a complaint alleging Facility staff neglected resident resulting in severely infected multiple pressure injuries. It has been alleged that staff neglected resident R1, resulting in multiple infected pressure injuries.

The Department reviewed medical report for R1’s hospital stay from April 6, 2021-April 9, 2021. The report stated R1 came to the hospital due to left heel and right mid foot ulceration, which was ongoing for a while. Furthermore, R1 was sent to urgent care by facility for “malodorous” foot wounds and R1 was found to have maggots in foot.

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Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2026
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-20210407163840
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: 10/05/2026
NARRATIVE
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On April 14, 2021 Licensing Program Analyst (LPA) Amy Kennedy conducted an unannounced visit to open a complaint investigation.

On June 18, 2021, the Department interviewed Hospice Nurse, (N1). N1 stated he/she made multiple visits to the facility to meet R1 regarding his/her hospice care; including wound care. N1 stated on April 6, 2021 he/she received a phone call from a Hospice Home Health Aide regarding wound care. N1 stated he/she made a visit and observed there were maggots on R1’s wound. N1 stated care staff at the facility never called him/her or hospice regarding any concerns they may have regarding R1: foul odors, soiled bandages or R1 complaining about having pain.

On June 24, 2021 the Department interviewed Executive Director (ED), Kandy Franklin. ED stated R1 has a history of pressure ulcers. ED stated R1 was placed on hospice care in January 2021. ED stated visits made by hospice care staff were 2x per week and later towards the end of March 2021 it was 3x per week. ED stated her staff were to monitor R1’s wounds and to notify hospice when the condition of the wound changes. ED acknowledged there was no communication between Hospice, PACE, and her staff related to R1’s wound care. ED accepted some of the responsibility regarding what happened that required R1 to be sent to the hospital for additional wound care. ED stated, “Ultimately, R1 was at our facility and under our care.”

The Department interviewed Wellness Coordinator (WC) Amy Castillo. WC stated she is familiar with R1. WC stated R1 had pressure ulcers on his/her coccyx and heels. WC stated his/her left foot was always wrapped with bandages. WC stated staff would have to contact hospice requesting a visit when there’s changes in R1’s health status/condition or when the bandages were soiled or loosened. WC stated on April 6, 2021, she received a phone call from PACE and was informed there were maggots on R1’s foot. WC stated R1 was then transferred to the hospital for additional medical treatment.

On July 2, 2021, the Department interviewed Hospice Doctor (HD). HD confirmed that R1 is one of his/her patients. HD stated R1 was certified to be on hospice care from January to April 2021. HD stated facility staff did not contact him/her for any new orders for wound care or medications for R1.

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SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 08-AS-20210407163840
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: 10/05/2026
NARRATIVE
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HD was asked if he/she was notified by the hospice nurse or facility staff regarding R1’s wound condition on April 6, 2021. HD stated he/she was not sure & stated he/she has many patients and could not recall any details regarding the visits. HD explained that maggots are developed in a few days due to an infection and do not develop overnight.

The Department interviewed staff S1. S1 stated he/she interacts with R1 very often, daily. S1 stated his/her understanding or instructions from hospice is not to provide any wound care to R1. S1 stated any issues/concerns regarding the pressure wounds or redressing the wounds will have to be done through hospice. S1 explained staff would call hospice and request a nurse to come out to assess and redress the bandages. S1 stated he/she did not notice any foul odor on R’s feet when he/she was in R1’s room.

The Department reviewed R1’s Plan of Care, dated March 18, 2021. The plan of care states, under skin maintenance- if resident has a change in skin condition ( infection, open areas, pressure sores), then care giver will notify nurse, family, and medical practitioner.

Based investigation conducted, facility staff were instructed to monitor and report any changes in R1’s condition. Staff reported PACE and Hospice did not provide them with any information or status regarding R1’s pressure wounds. But this does not absolve the facility’s responsibility to ask the licensed professional about any changes to R1’s medical conditions.

Furthermore there is no documentation from the facility showing they did their due diligence in documenting their observations or documentation showing they asked the medical professional who was visiting the facility at least 2x a week. The facility staff failed to communicate and/or obtain information from PACE and Hospice for R1 ; therefore, the allegation of Neglect/Lack of Care and Supervision of R1 is Substantiated.

Based on interviews and documents review the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED.

Report is reviewed and report is provided together with appeal rights.

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SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 08-AS-20210407163840
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: 10/05/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/06/2026
Section Cited
CCR
87466
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87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical … or deterioration of … physical health condition are observed, the … changes are documented and brought to the attention of the resident's physician …
This requirement was not met as evidence by:
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Licensee to submit a plan regarding in-service training for staff about Observation of Resident. Licensee to submit by POC deadline.
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Based on interviews and records reviewed, the facility did not ensure R1 was regularly observed for changes in physical health condition or document said changes. This poses an immediate health, safety and personal rights risk to residents in care.
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Type A
10/06/2026
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
This requirement was not met as evidence by:
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Licensee to submit a plan regarding in-service training for staff about Residents Personal Rights. Licensee to submit by POC deadline.
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Based on interviews and records reviewed, the facility did not monitor/report any of R1’s changes in condition and did not communicate with hospice regarding R1’s in condition. This poses an immediate health, safety and personal rights risk to residents 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: Brenda Chan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 4