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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604171
Report Date: 11/20/2023
Date Signed: 11/22/2023 10:50:58 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
02/06/2023 and conducted by Evaluator Iby Strong
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20230206145343
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: 63DATE:
11/20/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Executive Director Jared Green TIME COMPLETED:
04:40 PM
ALLEGATION(S):
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Medication was not issued as prescribed.
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 February 6, 2023, Community Care Licensing (CCL) received a complaint alleging licensee was not issuing medication as prescribed.

During investigation, LPA Strong collected pertinent resident records as well as facility documentation and conducted interviews. According to allegation, licensee did not order medication timely and medication was not distributed according to prescription. Additionally, on November 14, 2023, CCL received additional information alleging that medication is not being issued as prescribed as medication has been found on the floor of residents rooms.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023
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-20230206145343
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: 11/20/2023
NARRATIVE
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Interviews revealed that staff have found medication on the facility floor multiple times within the last six months. Interviews also revealed that staff did not receive medication order from pharmacy for Resident 1 (R1) until a few days after it was prescribed. During facility inspection on 11/20/23, LPA Strong observed three resident rooms with medication on the floor. Interviews revealed that staff could not confirm which resident the medication belonged to. Outside source interviews corroborated that residents have not received medications as prescribed.

Based on interviews, and records reviewed, 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). An exit interview was conducted with Executive Director Jared Green, to whom a copy of this report, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20230206145343
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: 11/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/27/2023
Section Cited
CCR
87465(c)(2)
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87465 Incidental Medical and Dental Care (c)(2)Once ordered by the physician the medication is given according to the physician's directions.
This requirement was not met as evidenced by:
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Licensee agrees to conduct vendorized training to staff by December 20, 2023 and provide proof of scheduled training by December 4, 2023.
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Based on interviews and observations licensee did not issue medication as prescribed in five of 65 persons in care which posed a potential health 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.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3