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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604171
Report Date: 09/28/2022
Date Signed: 09/28/2022 02:06:36 PM

Document Has Been Signed on 09/28/2022 02:06 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
CCLD Regional Office, 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: 55DATE:
09/28/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Kandy Franklin, Executive DirectorTIME COMPLETED:
11:51 AM
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Licensing Program Analyst (LPA) Dawn Segura conducted a case management visit to cite for a deficiency observed during a complaint investigation. LPA met with Kandy Franklin, Executive Director, and discussed the purpose of the visit.

During a complaint investigation, LPA discovered, through a review of records maintained by the facility and Resident 1’s (R1) [an LIC 811 Confidential Names List was provided to identify the resident] hospice agency that the facility documented a call to the hospice agency, following R1 being found on the floor in the facility, at a time that was 50 minutes earlier than hospice records reflect that the call was received from facility staff.

In response to the facility’s maintenance of inaccurate documentation, a deficiency is being cited Per Title 22, Division 6, Chapter 8 of the California Code of Regulations and is listed on an LIC 809-D.

An exit interview was conducted, and this report was discussed with Kandy Franklin. Copies of this report and Licensee/Appeal Rights (LIC 9058) were provided to the Executive Director, and her signature on this form acknowledges receipt of the rights and a copy of this report.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dawn Segura
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/28/2022 02:06 PM - It Cannot Be Edited


Created By: Dawn Segura On 09/28/2022 at 10:32 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: LO-HAR SENIOR LIVING
FACILITY NUMBER: 374604171

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/14/2022
Section Cited
CCR
87207

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No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement was not met as evidenced by:

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Executive Director offered to conduct training and ensure that outside vendor training is provided to all med techs and caregivers to ensure that accurate and timely charting is completed. Proof of training is to be provided to Cmmunity Care Licensing by the POC due date of 10/14/2022.
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Based upon LPA’s record review, licensee documented false information in records maintained for 1 of 55 residents in care. This posed a potential health and safety 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:Lizzette Tellez
LICENSING EVALUATOR NAME:Dawn Segura
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2022


LIC809 (FAS) - (06/04)
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